Daily Living Skills-Mental Health PDF

DAILY LIVING SKILLSMENTAL HEALTH A/PTanBhingLeet Director of Programmes Singapore Institute of Technology This is an overview of Daily Living Skills in mental health. 1 CONTENTS 1. Difficulties in Activities of Daily Living (ADL) 2. Difficulties in Instrumental Activities of Daily Living (IADL) 3. A...

DAILY LIVING SKILLSMENTAL HEALTH A/PTanBhingLeet Director of Programmes Singapore Institute of Technology This is an overview of Daily Living Skills in mental health. 1 CONTENTS 1. Difficulties in Activities of Daily Living (ADL) 2. Difficulties in Instrumental Activities of Daily Living (IADL) 3. ADL/IADL Difficulties in Depression 4. ADL/IADL Difficulties in Schizophrenia 5. ADL/IADL Assessments: Observational 6. Performance Based ADL/IADL Assessments These are the contents. 2 Difficulties With Activities of Daily Living (ADL) ▪ In mental health, problems with ADL usually related to cognitive, psychological, or sensory issues and less frequently due to motor impairments (Brown & Stoffel, 2011). ▪ Range from minor problems (such as poor nail care) to total dependence across all ADLs in severe mental illness. ▪ ADL can be affected in persons: at acute stage of mental illness (eg: depression, psychosis) who experience negative symptoms and/or cognitive problems associated with schizophrenia who are institutionalized Brown, C., & Stoffel, V. C. (Eds.). (2011). Occupational Therapy in Mental Health: A Vision for Participation. Philadelphia: F. A. Davis Company. In mental health, difficulties with ADL are usually related to cognitive, psychological, or sensory issues and less frequently due to motor impairments. Extent of problems in ADL/IADL can range from minor ones such as poor nail care to total dependence across all ADLs in severe mental illness. ADL can be affected in persons: at the acute stage of mental illness (such as: depression, psychosis) who experience negative symptoms and/or cognitive problems associated with schizophrenia and those who are institutionalized. 3 Difficulties With Instrumental Activities of Daily Living (IADL) ▪ ▪ IADL performance is based on a complex interaction of : skill knowledge and experience, underlying abilities (such as cognitive, emotional, social) environmental resources. Individual must first have the opportunity to learn the skill. Onset of schizophrenia often in late teens or early 20s (Walker, Kestler, Bollini, & Hochman, 2004): fewer opportunities to experience and learn IADLs as part of the typical adult development process. Individuals in institutional or sheltered settings: few naturally occurring opportunities to engage in certain IADLS (such as making monetary transactions, taking public transportation and grocery shopping). IADL performance is based on a complex interaction of skill knowledge and experience, underlying abilities (such as cognitive, emotional, social), as well as environmental resources. Therefore, the individual must first have the opportunity to learn the skill. The onset of schizophrenia is often in the late teens or early 20s (Walker, Kestler, Bollini, & Hochman, 2004), which render many individuals with schizophrenia with few opportunities to experience and learn IADLs as part of the typical adult development process. Some individuals with mental illness who have lived in institutional or sheltered settings may not have had the naturally occurring opportunities to engage in certain IADLS, such as making monetary transactions, taking public transportation and grocery shopping. Due to complexity of IADLs, they place high demands on cognitive and social skills; therefore, individuals with underlying cognitive and social impairments often have problems with IADLs. 4 ▪ ▪ IADLs, place higher demands on cognitive and social skills (Brown & Stoffel, 2011). Therefore, individuals with underlying cognitive and social impairments often have problems with IADLs: a person with schizophrenia may have difficulties remembering items on the grocery list and has difficulties sustaining attention when cooking. a person with social anxiety may have difficulties riding on a crowded MRT. Emotional factors may also interfere with performance of IADLs: a housewife with major depressive disorder may experience psychomotor retardation, which makes it difficult for her to complete household chores. IADLs, are more complex and thus place high demands on cognitive and social skills. Therefore, individuals with underlying cognitive and social impairments often have problems with IADLs. For example, a person with schizophrenia may have difficulties remembering items on the grocery list and has difficulties sustaining attention when cooking. A person with social anxiety may have difficulties riding on a crowded MRT. Emotional factors may also interfere with performance of IADLs. A housewife with major depressive disorder may experience psychomotor retardation, which makes it difficult for her to complete household chores. 5 ADL/IADL Difficulties in Depression ▪ Persons with depression: 4.3 times more likely to have problems performing at least one ADL task (dress, toilet, bathe, eat, walk across a room, and transfer in and out of bed) for a time period of at least 3 months (Dunlop, Manheim, Song, Lyons, & Chang, 2005). ▪ Severely depressed adults,: cognition associated with Instrumental Activities of Daily Living (IADLs); severity of depression closely related to basic ADLs (McCall & Dunn, 2003). ▪ Often not due to lack of knowledge and skills to perform the ADL, but a lack of volition, interest, attention or drive for engagement in self-care. Persons with depression are 4.3 times more likely to have problems performing at least one ADL task for a time period of at least 3 months. The ADL task may include dressing, toileting, bathing, eating, walking across a room, and transferring in and out of bed. In a study of severely depressed adults, cognition was associated with IADLs, whereas severity of depression was closely related to basic ADLs. Unlike intellectual disability, problems in ADL in depression is often not due to lack of knowledge and skills to perform the ADL, but a lack of volition, interest, attention or drive for engagement in self-care. 6 ADL/IADL Difficulties in Schizophrenia ▪ High proportion of persons with schizophrenia experience difficulties in instrumental activities of daily living, financial management, decision-making and community mobility (Perivoliotis, Granholm, & Patterson, 2004). ▪ Problems with self-care, as well as underactivity and slowness due to negative symptoms, often become increasingly pronounced at one to five years upon the initial onset of the illness and remain fairly stable thereafter (Häfner & an der Heiden, 1999). ▪ This results in residential and financial dependence (Aubin, Stip, Gelinas, Rainville, & Chapparo, 2009). A high proportion of people suffering from schizophrenia experience difficulties in instrumental activities of daily living, financial management, decision-making and community mobility (Perivoliotis, Granholm, & Patterson, 2004). Problems with self-care, as well as underactivity and slowness due to negative symptoms, often become increasingly pronounced at one to five years upon the initial onset of the illness and remain fairly stable thereafter (Häfner & an der Heiden, 1999). This results in residential and financial dependence (Aubin, Stip, Gelinas, Rainville, & Chapparo, 2009). 7 ▪ Study of 72 outpatients with schizophrenia: only 14 of them lived in their own residence without any supervision (Dickerson, Ringel, & Parente, 1999). The rest lived with either caregivers, sheltered housing and groups homes or their own residences with drop-in supervision. ▪ 13-year follow-up study of people with early onset of schizophrenia: 48% of them were still living with their parents while 33.3% of them were in assisted or semi-assisted housing (Reichert, Kreiker, Mehler-Wex, & Warnke, 2008). ▪ Poorer performance of activities of daily living, lower participation in social and recreational activities and relationships, poorer social presentation, and negative symptoms predicted residential dependence (Sharma & Antonova, 2003). In a study of 72 outpatients with schizophrenia, only 14 of them lived in their own residence without any supervision (Dickerson, Ringel, & Parente, 1999). The rest lived with either caregivers, sheltered housing and groups homes or their own residences with drop-in supervision. In a follow-up study of people with early onset of schizophrenia 13 years later, 48% of them were still living with their parents while 33.3% of them were in assisted or semi-assisted housing (Reichert, Kreiker, Mehler-Wex, & Warnke, 2008). It was found that poorer performance of activities of daily living, lower participation in social and recreational activities and relationships, poorer social presentation, and negative symptoms predicted residential dependence (Sharma & Antonova, 2003). 8 ▪ Cognitive performance of persons with schizophrenia: between 1.5 to 2 standard deviations below norm (Schretlen, 2007). ▪ Persons with early psychosis and schizophrenia experience difficulties in independently living, associated with cognitive problems (Higuchi et al., 2017). ▪ Studies have also delineated specific neurocognitive domains that are predictive of community functioning (Bowie, et al., 2006; Dickinson & Coursey, 2002; Shamsi et al., 2011). Cognitive performance of persons with schizophrenia: is found to be between 1.5 to 2 standard deviations below norm (Schretlen, 2007). Persons with early psychosis and schizophrenia often experience difficulties in independently living which are associated with cognitive problems (Higuchi et al., 2017). Studies have also delineated specific neurocognitive domains that are predictive of community functioning (Bowie, et al., 2006; Dickinson & Coursey, 2002; Shamsi et al., 2011). 9 ADL/IADL Assessments: Observational Now, we will look at a few ADL and IADL assessments, which are observational in nature. 10 Routine Task Inventory- Expanded ▪ Based on Claudia Allen’s Cognitive Disability Model (Katz, 2006). ▪ Routine task behavior : occupational performance in areas of self care, instrumental activities at home and in the community, social communication through verbal and written comprehension and expression, and readiness for work relations and performance. ▪ Aim of the assessment: promote the safe, routine performance of an individual’s valued occupations and to maximize participation in life situations The Routine Task Inventory-Expanded, or RTI-E is based on Claudia Allen’s Cognitive Disability Model. In this assessment, routine task behavior is defined as Occupational Performance in areas of self care, instrumental activities at home and in the community, social communication through verbal and written comprehension and expression, and readiness for work relations and performance. Hence, the scale consists of Physical Scale-ADL Community Scale-IADL Communication Scale Work Readiness Scale The aim of the assessment of routine task behavior is to promote the safe, routine performance of an individual’s valued occupations and to maximize participation in life situations. 11 This is a snapshot of the Physical Scale-ADL. It consists of ADL such as grooming, bathing, walking/exercising and feeding. 12 For example in this Physical Scale ADL section, a patient may not match make up to skin tones and may neglect the back of the head or body during grooming. So in this case, she will score 4 under grooming. Under dressing, if she disregards the appearance of the back of the garment, she may also get a score of 4. Under bathing, if she needs to be reminded to bathe and not bathe entire body unless given verbal or tactile direction and if she does not follow typical procedure, neglecting to use soap, rise or dry, she will score 3. Under walking/exercising, if she walks in familiar surrounding without getting lost and can be trained to follow an exercise program after weeks of practice; and refuses to go to unfamiliar places, she will also get a score of 4 under this task. 13 This is a snapshot of Community Scale-IADL. It consists of IADLs such as housekeeping, spending money, doing laundry, travelling and shopping 14 This is a snapshot of the Communication Scale, which consists of areas such as listening/comprehension; talking/expression; reading/comprehension and writing/expression. 15 This is a snapshot of the Work Readiness Scale. It consists of areas such as maintaining pace/schedule; performing simple/complex tasks; getting along with co-workers and planning work/supervising others. 16 ▪ 3 sources of information used to complete the functional assessment: patient self report, family member/other caregiver and observations of performance. ▪ The Therapist Report describes the judgments of a therapist who has observed the individual perform at least four of the tasks within the area being scored. ▪ To report which tasks observed and the duration of the observations in the reporting form. ▪ Scoring of the RTI-E based on familiarity with the client assessed and observations done during several days in different contexts. It is not based on a one time structured task performance. ▪ A team of therapists who observed the client on different tasks can collaborate to score the RTI-E. Important to establish inter-rater agreement. ▪ The therapists generally score the highest level at which there is a clear pattern of performance. Katz, N. (2006). Routine Task Inventory – RTI-E manual, prepared and elaborated on the basis of Allen, C.K. (1989 unpublished). 3 sources of information used to complete the functional assessment: patient self report, family member/other caregiver and observations of performance. The Therapist Report describes the judgments of a therapist who has observed the individual perform at least four of the tasks within the area being scored. The therapist must report which tasks were observed and the duration of the observations in the reporting form. The therapist may only record behaviors which he/she has directly observed. The scoring of the RTI-E is based on familiarity with the client assessed and observation done during several days in different contexts. It is not based on a one time structured task performance and therefore referred to as routine task performance. It could be also a team of therapists who observed the client on different tasks and collaborate in scoring the RTI-E. In this case it is important that the therapists establish inter rater agreement between them on scoring the RTI-E. Therapists then score the highest level at which there is a clear pattern of performance. 17 Multnomah Community Ability Scale (MCAS) ▪ A clinician-rated tool which is widely used to measure community independence (MCAS, 2004). ▪ The MCAS-R covers 17 indicator items grouped into 4 Sections: a. Health b. Adaptation c. Social Skills d. Behaviour MCAS. (2004). Multnomah Community Ability Scale User’s Manual. Portland: Network Ventures Inc The Multnomah Community Ability Scale (MCAS), a clinician-rated tool which is widely used to measure community independence(Bassani et al., 2009). The MCAS-R covers 17 indicator items grouped into 4 Sections: Health Adaptation Social Skills Behavior 18 Adaptation Section: the person’s functioning in daily life and how well he/she has adapted to living with mental illness over the past 30 days. The Adaptation Section pertains to the person’s functioning in daily life and how well he/she has adapted to living with mental illness over the past 30 days. 19 ▪ Total MCAS score enables clinicians to compare a person’s level of ability with that of the larger population of people with psychiatric disabilities living in the community. ▪ If scale is completed every three to six months, a profile of client change can be obtained. The total MCAS score enables clinicians to compare a person’s level of ability with that of the larger population of people with psychiatric disabilities living in the community. If scale is completed every three to six months, a profile of client change can be obtained. 20 Standardised Performance Based ADL/IADL Assessments Next, we move on to standardised performance based ADL/IADL assessments. 21 Kohlman Evaluation of Living Skills (KELS) ▪ Originally created in 1978 for use in short-term inpatient psychiatric units. ▪ Subsequently used with older adults, persons with brain injury and in acute care hospitals. ▪ Not suitable in long term care settings (person’s financial, transportation, work and leisure resources have usually changed). ▪ Combines interview items with simulated performance. ▪ Tests 13 living skills in 5 areas: ▪ 1. Self care 2. Safety and health 3. Money management 4. Community mobility and telephone 5. Employment and leisure participation Goal of KELS: provide information to match a living environment with person’s strengths, enabling person to live safely in the least restrictive environment (Thomson & Robnett, 2016). The Kohlman Evaluation of Living Skills (KELS) was originally created in 1978 for use in short-term inpatient psychiatric units. It was subsequently used with older adults, persons with brain injury and in acute care hospitals. It is not suitable in long term care settings, because the person’s financial, transportation, work and leisure resources have usually changed dramatically as a result of long length of stay in the institution. The KELS combines interview items with simulated performance and tests 13 living skills in 5 areas: 1. Self care 2. Safety and health 3. Money management 4. Community mobility and telephone 5. Employment and leisure participation The goal of KELS is to provide information to match a living environment with person’s strengths, enabling person to live safely in the least restrictive environment (Thomson & Robnett, 2016). 22 Money Management: 2. Payment of Bills The 4th edition of KELS address the many ways that people currently access different types of telephones, obtaining telephone information and making monetary transactions. For example under payment of bills of the Money Management section, an electronic banking option is added using Flash Drive, for clients to demonstrate payment of bills using electronic banking option. 23 ▪ Overall score has been eliminated in the 4th edition. ▪ Critical to acknowledge the importance of the effects of physical and social aspects of an environment on a person’s function: person who has multiple items scored as ‘Needs Assistance’ may be able to live at home alone with right amount of assistance and monitoring. ▪ Recommendations: the OT must examine the items scored as ‘Needs Assistance’ and compares them with the assistance available to the client in different types of settings and in the community. Thomson, L. K., & Robnett, R. (2016). Kohlman Evaluation of Living Skills. Bethesda: American Occupational Therapy Association. The overall score has been eliminated in the 4th edition, because of limited amount of research done on KELS’ composite score. It is also critical to acknowledge the importance of the effects of physical and social aspects of an environment on a person’s function. A person who has multiple items scored as ‘Needs Assistance’ may be able to live at home alone with right amount of assistance and monitoring. Under Recommendations, the OT must examine the items scored as ‘Needs Assistance’ and compares them with the assistance available to the client in different types of settings and in the community. 24 ▪ Several validity and reliability studies done on the earlier versions of KELS. ▪ 3rd edition of KELS was compared with the Milwaukee Evaluation of Daily Living Skills (MEDLS) and showed significant correlations (Leonardelli, 1989). ▪ Scores on KELS were also compared with Functional Independence Measure (Uniform Data System for Medical Rehabilitation, 2002), Mini Mental State Examination and Routine Task Inventory (Allen, Earhart, & Blue, 1992), with high correlations. ▪ Content validity was examined for the 4th edition of KELS in 2014 and results were positive (Thomson & Robnett, 2016). Thomson, L. K., & Robnett, R. (2016). Kohlman Evaluation of Living Skills. Bethesda: American Occupational Therapy Association. There were several validity and reliability studies done on the earlier versions of KELS. The 3rd edition of KELS was compared with the Milwaukee Evaluation of Daily Living Skills (MEDLS) and showed significant correlations (Leonardelli, 1989). Scores on KELS were also compared with Functional Independence Measure (Uniform Data System for Medical Rehabilitation, 2002), Mini Mental State Examination and Routine Task Inventory (Allen, Earhart, & Blue, 1992), with high correlations. Content validity was examined for the 4th edition of KELS in 2014 and results were positive (Thomson & Robnett, 2016).. 25 Milwaukee Evaluation of Daily Living Skills (MEDLS) ▪ Assessment of basic daily living skills for persons with chronic mental illness in long term care settings (Leonardelli, 1989). ▪ Many items are still suitable for use in local long term care settings, especially those catered for persons with chronic mental health conditions. ▪ Measurement of behavioural performance of skills whenever feasible with minimum self-report. ▪ Can be used alongside OT models such as Model of Human Occupation. ▪ 20 subtests. Maximum time allowed for completion of tasks ▪ Screening form: to help determine which areas need evaluation. ▪ Each subtest is scored separately. No composite score. Next, I would like to introduce the Milwaukee Evaluation of Daily Living Skills. It is an assessment of basic daily living skills for persons with chronic mental illness in long term care settings (Leonardelli, 1989). It is an old assessment developed in the 1980s, but many items are still suitable for use in local long term care settings, especially those catered for persons with chronic mental health conditions. The MEDLS is a measurement of behavioural performance of skills whenever feasible with minimum self-report. It can be used alongside OT models such as Model of Human Occupation. There are 20 subtests in this scale and maximum time allowed for completion of tasks are indicated in the subtests. There is also a screening form: to help the OT determine which areas need evaluation. Each subtest is scored separately and there is no composite score. 26 Subtests 1. Basic communication skills 11. Medication management 2. Bathing 12. Nail care 3. Brushing teeth 13. Personal health care 4. Denture care 14. Safety in the community 5. Dressing 15. Safety in home 6. Eating 16. Shaving 7. Eyeglass care 17. Time awareness 8. Hair care 18. Use of money 9. Maintenance of clothing 19. Use of telephone 10. Make-up use 20. Use of transportation Leonardelli, C. A. (1989). The Milwaukee Evaluation of Daily Living Skills. Thorofare: Slack Incorporated. As you can see, the subtests are very comprehensive. However, some of the subtests such as subtest 18 ‘Use of money’ is based on American currency. Subtest 19 ‘Use of telephone’ may also be outdated. 27 Subtest 3: Brushing Teeth Each subtest has specific instructions on the equipment, instructions to client, time limit and scoring criteria. For example in this subtest on Brushing Teeth, the client has to perform all the 4 listed skills of……… in order to score 4 points. If he/she is unable to perform skill b, he/she will have a score of 3 and the key word of ‘brush’ will be written in the Reporting Form. 28 References ▪ Allen, C. K., Earhart, C. A., & Blue, T. (1992). Occupational Therapy Treatment Goals for the Physically and Cognitively Disabled. Bethesda: American Occupational Therapy Association. ▪ Aubin, G., Stip, E., Gelinas, I., Rainville, C., & Chapparo, C. (2009). Daily Activities, Cognition And Community Functioning In Persons With Schizophrenia. Schizophrenia Research, 107, 313-318. ▪ Bowie, C. R., Reichenberg, A., Patterson, T. L., Heaton, R. K., & Harvey, P. D. (2006). Determinants of Real-World Functional Performance in Schizophrenia Subjects:Correlations With Cognition, Functional Capacity, and Symptoms. The American Journal of Psychiatry, 163(3), 418-425. ▪ Brown, C., & Stoffel, V. C. (Eds.). (2011). Occupational Therapy in Mental Health: A Vision for Participation. Philadelphia: F. A. Davis Company. ▪ Dickerson, F. B., Ringel, N., & Parente, F. (1999). Predictors of Residential Independence Among Outpatients With Schizophrenia. Psychiatric Services, 50(4), 515-519. ▪ Dickinson, D., & Coursey, R. D. (2002). Independence and Overlap Among Neurocognitive Correlates of Community Functioning in Schizophrenia. Schizophrenia Research, 56, 161-170. ▪ Dunlop, D. D., Manheim, L. M., Song, J., Lyons, J. S., & Chang, R. W. (2005). Incidence of Disability Among Preretirement Adults: the Impact of Depression. American Journal of Public Health, (95), 2003–2008. We’ve come to the end of the lecture. These are the references. 29 ▪ Häfner, H., & an der Heiden, W. (1999). The Course of Schizophrenia in the Light of Modern Follow-up Studies: the ABC and WHO Studies. European Archives of Psychiatry and Clinical Neurosciences, 249 ((Suppl. 4)), 14–26. ▪ Higuchi, Y., Sumiyoshi, T., Seo, T., Suga, M., Takahashi, T., Nishiyama, S., … Suzuki, M. (2017). Associations between daily living skills, cognition, and real-world functioning across stages of schizophrenia; a study with the Schizophrenia Cognition Rating Scale Japanese version. Schizophrenia Research: Cognition , 7, 13–18. http://doi.org/10.1016/j.scog.2017.01.001 ▪ Katz, N. (2006). Routine Task Inventory – RTI-E manual, prepared and elaborated on the basis of Allen, C.K. (1989 unpublished). ▪ Kim, S.-J., Shim, J.-C., Kong, B.-G., Kang, J.-W., Moon, J.-J., Jeon, D.-W., … Jung, D.-U. (2015). Differences in cognitive function and daily living skills between early- and late-stage schizophrenia. International Journal of Psychiatry in Clinical Practice, 19(4), 246–252. http://doi.org/10.3109/13651501.2015.1084328 ▪ Leonardelli, C. A. (1989). The Milwaukee Evaluation of Daily Living Skills. Thorofare: Slack Incorporated. ▪ MCAS. (2004). Multnomah Community Ability Scale User’s Manual. Portland: Network Ventures Inc. ▪ McCall, W. V., & Dunn, A. G. (2003). Cognitive Deficits Are Associated With Functional Impairment in Severely Depressed Patients. Psychiatry Research, 121, 179–184. 30 ▪ Patterson, T. D. (2006). UCSD Performance-Based Skills Assessment-Brief Version (UPSA-B) Administration and Scoring Manual. La Jolla. ▪ Patterson, T. L., Goldman, S.,McKibbin, C. L.,Hughs, T., & Jeste,D.V. (2001). UCSD Performance Based Skills Assessment: Development of a new measure of everyday functioning for severely mentally ill adults. Schizophrenia Bulletin, 27, 235–245. ▪ Patterson, T. L., McKibben, C., Taylor, M., Goldman, S., Davila- Fraga,W., Bucardo, J., & Jeste, D. (2003). Functional Adaptation Skills Training: A pilot psychosocial intervention study in middle-aged and older patients with chronic psychotic disorders. American Journal of Geriatric Psychiatry, 11, 17–23. ▪ Perivoliotis, D., Granholm, E., & Patterson, T. L. (2004). Psychosocial Functioning On The Independent Living Skills Survey In Older Outpatients With Schizophrenia. Schizophrenia Research, 69, 307-316. ▪ Reichert, A., Kreiker, S., Mehler-Wex, C., & Warnke, A. (2008). The Psychopathological and Psychosocial Outcome of Early-Onset Schizophrenia: Preliminary Data of a 13-Year Follow-Up. Child Adolescence Psychiatry and Mental Health, 2(1), 6. ▪ Shamsi, S., Lau, A., Lencz, T., Burdick, K. E., Derosse, P., Brenner, R., et al. (2011). Cognitive And Symptomatic Predictors Of Functional Disability In Schizophrenia. Schizophrenia Research, 126 (1-3), 257–264. ▪ Sharma, T., & Antonova, L. (2003). Cognitive Function in Schizophrenia: Deficits, Functional Consequences, and Future Treatment. Psychiatric Clinics of North America. 26, 25-40 31 ▪ ▪ ▪ ▪ Schretlen, D.J., 2007. The nature and significance of cognitive impairment in schizophrenia —. Adv. Stud. Med. 7, 72–78. Thomson, L. K., & Robnett, R. (2016). Kohlman Evaluation of Living Skills. Bethesda: American Occupational Therapy Association. Twamley, E.W.,Doshi, R. R.,Nayak, G.V., Palmer, B.W., Golshan, S., Heaton, R. K., Patterson, T. L., & Jeste, D. V. (2002). Generalized cognitive impairments, ability to perform everyday tasks and level of independence in community living situations of older patients with psychosis. American Journal of Psychiatry, 159, 2013–2020. Uniform Data System for Medical Rehabilitation. (2002). FIM Clinical Guide Version 5.01. Buffalo: State University of New York at Buffalo. ▪ Walker, E., Kestler, L., Bollini, A., & Hochman, K. M. (2004). Schizophrenia: Etiology and Course. Annual Review of Psychology, 55, 401–430. ▪ Wallace, C. J., Liberman, R. P., Tauber, R., & Wallace, J. (2000). The independent living skills survey: a comprehensive measure of the community functioning of severely and persistently mentally ill individuals. Schizophrenia Bulletin, 26(3), 631–658. http://doi.org/10.1093/oxfordjournals.schbul.a033483 ▪ 32 The End 33