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Measuring Patient-Centered Outcomes in Neurologic Disease: Extending the Q-TWiST Method

Measuring Patient-Centered Outcomes in Neurologic Disease: Extending the Q-TWiST Method Abstract Background: Current clinical research and outcomes assessment on multiple sclerosis rely on an approach to disability measurement that is heavily influenced by ambulation. Not only is this strategy often insensitive to the clinical changes affected by pharmacotherapeutic or rehabilitative interventions but it also disregards the symptoms that patients seem to consider most enervating. We propose a new method for evaluating clinical interventions in terms of their impact on the symptoms of multiple sclerosis, side effects, parameters of exacerbation, and disease progression, while considering the patient's perspective. Methods: The extended Q-TWiST method yields an estimation of treatment trade-offs in terms of Quality-adjusted Time Without Symptoms and Toxicities (Q-TWiST). An illustration of this method is presented by using a hypothetical clinical trial of two treatments. The trade-offs between the two treatments are highlighted to facilitate treatment decision making by using individual patient importance weights. Conclusion: We discuss applications to other clinical research and other chronic diseases. References 1. Moss R. Toward the golden city . Agni . 1992;35:111. 2. Bauer C. From the patient's point of view . J Cogn Rehabil . 1992;10:9. 3. Fisk JD, Pontefract A, Ritvo P, Archibald CJ, Murray TJ. The impact of fatigue on patients with multiple sclerosis . Can J Neurol Sci . 1994;18( (suppl 1) ):79-83. 4. Noseworthy JH. Therapeutics of multiple sclerosis . Clin Neuropharmacol . 1991; 14:49-61.Crossref 5. Schumacher GA, Beebe G, Kibler RF, et al. Problems of experimental trials of therapy in multiple sclerosis: report by the Panel on the Evaluation of Experimental Trials of Therapy in Multiple Sclerosis . Ann N Y Acad Sci . 1965;122: 552-568.Crossref 6. Poser S. Management of patients with multiple sclerosis . In: Koestler JC, ed. Handbook of Clinical Neurology: Demyelinating Diseases . New York, NY: Elsevier Science Publishing Co Inc; 1985;3:147-186. 7. Trotter JL, Garvey WF. Prolonged effects of large-dose methylprednisolone infusion in multiple sclerosis . Neurology . 1980;30:702-708.Crossref 8. Lechtenberg R. Multiple Sclerosis Fact Book . Philadelphia, Pa: FA Davis Co Publishers; 1988. 9. Gelber RD, Goldhirsch A. A new endpoint for the assessment of adjuvant therapy in postmenopausal women with operable breast cancer . J Clin Oncol . 1986; 4:1772-1779. 10. Goldhirsch A, Gelber RD, Simes J, Glasziou P, Coates AS, for the Ludwig Breast Cancer Study Group. Costs and benefits of adjuvant therapy in breast cancer: a quality-adjusted survival analysis . J Clin Oncol . 1989;7:36-44. 11. Penn RD, Savoy SM, Corcos D, et al. Intrathecal baclofen for severe spinal spasticity . N Engl J Med . 1989;320:1517-1521.Crossref 12. Cohen RA, Fisher M. Amantadine treatment of fatigue associated with multiple sclerosis . Can J Neurol Sci . 1989;14:273-278. 13. Blaivas JG, Holland NJ, Geisser B, LaRocca N, Madonna M, Scheinberg L. Multiple sclerosis bladder: studies and care . Ann N Y Acad Sci . 1984;436:328-345.Crossref 14. Broman T. Management of patients with multiple sclerosis . In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology, IX . New York, NY: Elsevier Science Publishing Co Inc; 1970:408-425. 15. Allshouse KD. Treating patients as individuals . In: Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the Patient's Eyes . San Francisco, Calif: Jossey-Bass Inc Publishers; 1993:19-44. 16. The Canadian Cooperative Multiple Sclerosis Study Group. The Canadian cooperative trial of cyclophosphamide and plasma exchange in progressive multiple sclerosis . Lancet . 1991;337:441-446. 17. Hauser SL, Dawson DM, Lehrich JR, et al. Intensive immunosuppression in progressive multiple sclerosis: a randomized, three-arm study of high-dose intravenous cyclophosphamide, plasma exchange, and ACTH . N Engl J Med . 1983;308:173-180.Crossref 18. Noseworthy JH, Vandervoot MK, Ebers GC, and the Canadian Cooperative Multiple Sclerosis Study Group. Acceptance of placebo-controlled trial design by progressive multiple sclerosis patients . Neurology . 1989;39:606-607. 19. Leo GJ, Rao SM. Effects of intravenous physostigmine and lecithin on memory loss in multiple sclerosis: report of a pilot study . J Neurol Rehabil . 1988;2: 123-129. 20. LaRocca NG. A rehabilitation perspective . In: Rao SM, ed. Neurobehavioral Aspects of Multiple Sclerosis . New York, NY: Oxford University Press Inc; 1990: 215-229. 21. Sullivan MJL, Dehoux E, Buchanan DC. An approach to cognitive rehabilitation in multiple sclerosis . Can J Rehabil . 1989;3:77-85. 22. Rao SM, Leo, GJ, Ellington LS, Nauertz T, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis, II: impact on employment and social functioning . Neurology . 1991;41:692-696.Crossref 23. Foley FW, Iverson J. Sexuality in multiple sclerosis . In: Kalb R, ed. The Family and Multiple Sclerosis . New York, NY: Demos Publications; 1992:63-82. 24. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis, I: frequency, patterns, and prediction . Neurology . 1991;41:685-691.Crossref 25. Schwartz CE. Awareness and cognitive deficit in multiple sclerosis . Psychosom Med . 1993;55:130. Abstract. 26. Kurtzke JF. On the evaluation of disability in multiple sclerosis . Neurology . 1961; 11:686-694.Crossref 27. Kurtzke JF. Further notes on disability evaluation in multiple with scale modifications . Neurology . 1965;15:654-661.Crossref 28. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an Expanded Disability Status Scale (EDSS) . Neurology . 1983;33:1444-1452.Crossref 29. Kurtzke JF. Neuroepidemiology, II: assessment of therapeutic trials . Ann Neurol . 1986;19:311-319.Crossref 30. Pia Amato M, Fratiglioni L, Groppi C, Siracusa G, Amaducci L. Interrater reliability in assessing functional systems and disability on the Kurtzke scale in multiple sclerosis . Arch Neurol . 1988;45:746-748.Crossref 31. Noseworthy JH, Vandervoort MK, Wong CJ, Ebers GC, and the Canadian Cooperative MS Study Group. Interrater variability with the Expanded Disability Status Scale (EDSS) and Functional Systems (FS) in a multiple sclerosis clinical trial . Neurology . 1990;40:971-975.Crossref 32. Kurtzke JF. Disability rating scales in multiple sclerosis . Ann N Y Acad Sci . 1984;436:347-360.Crossref 33. The IFNB Multiple Sclerosis Study Group. Interferon beta-1b is effective in relapsing-remitting multiple sclerosis, I: clinical results of a multicenter, randomized, double-blind, placebo-controlled trial . Neurology . 1993;43:655-661.Crossref 34. Paty DW, Li DKB, the UBC MS/MRI Study Group, and the IFNB Multiple Sclerosis Study Group. Interferon beta-1 b is effective in relapsing-remitting multiple sclerosis, II: MRI analysis results of a multicenter, randomized, doubleblind, placebo-controlled trial . Neurology . 1993;43:662-667.Crossref 35. Tyler LE. Tests and Measurements . 2nd ed. Englewood Cliffs, NJ: Prentice-Hall International Inc; 1971:6. 36. Hohol MJ, Khoury SJ, Hafler DA, et al. Disease Steps in multiple sclerosis: a simple approach to classify patients and evaluate disease progression . Neurology . 1993;43:A203-A204. 37. Gelber RD, Lenderking WR, Cotton DJ, et al. Quality-of-life evaluation in a clinical trial of zidovudine therapy in patients with mildly symptomatic HIV infection . Ann Intern Med . 1992;116:961-966.Crossref 38. Gelber RD, Cole BF, Goldhirsch A. Comparing treatments using qualityadjusted survival: the Q-TWiST method. Am Stat. In press. 39. Cole BF, Gelber RD, Anderson KM. Parametric approaches to quality-adjusted survival analysis . Biometrics . 1994;50:621-631.Crossref 40. Glasziou PP, Simes RJ, Gelber RD. Quality-adjusted survival analysis . Stat Med . 1990;9:1259-1276.Crossref 41. Guyatt GH, Jaeschke R. Measurements in clinical trials: choosing the appropriate approach . In: Spilker B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press; 1990:37-46. 42. Nunnally JC. Psychometric Theory . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1978:210-214. 43. Torrance GW, Thomas WH, Sackett DL. A utility maximization model for evaluation of health care programs . Health Serv Res . 1972;7;118-1133. 44. von Neumann J, Morgenstern O. The Theory of Games and Economic Behavior . New York, NY: John Wiley & Sons Inc; 1953. 45. Torrance GW, Boyle MH, Horwood SP. Application of multi-attribute utility theory to measure social preferences for health states . Operations Res . 1982;30: 1043-1069.Crossref 46. Rudick RA. Betaseron for multiple sclerosis: implications for therapeutics . Arch Neurol . 1994;51:125-127.Crossref 47. Burnham JA, Wright R, Dreisbach J, Murray RS. The effect of high-dose steroids on MRI gadolinium enhancement in acute demyelinating lesions . Neurology . 1991;41:1349-1354.Crossref 48. Poser CM. A numerical scoring system for the classification of multiple sclerosis . Acta Neurol Scand . 1979;60:100-111.Crossref 49. Radloff L. The CES-D scale: a self-report depression scale for research in the general population . Appl Psychol Measurement . 1977;1:385-401.Crossref 50. Coyle CP, Roberge JJ. The psychometric properties of the Center for Epidemiologic Studies—Depression Scale (CES-D) when used with adults with physical disabilities . Psychol Health . 1993;7:69-81.Crossref 51. Weiss W, Dambrosia JM. Common problems in designing therapeutic trials in multiple sclerosis . Arch Neurol . 1983;40:678-680.Crossref 52. Krupp LB, Alvarez LA, LaRocca NG, Scheinberg LC. Fatigue in multiple sclerosis . Arch Neurol . 1988;45:435-437.Crossref 53. Frankl DI. Multiple sclerosis . In: Umphred D, ed. Neurological Rehabilitation . 2nd ed. St Louis, Mo: Mosby—Year Book Inc; 1990:531-549. 54. Weiner HL, Mackin GA, Matsui M, et al. Double-blind pilot trial of oral tolerization with myelin antigens in multiple sclerosis . Science . 1993;259:1321-1324.Crossref 55. Bourdette DN, Prochazka AV, Mitchell W, Licari P, Burks J, and the VA Multiple Sclerosis Rehabilitation Study Group. Health care costs of veterans with multiple sclerosis: implications for the rehabilitation of MS . Arch Phys Med Rehabil . 1993;74:26-31. 56. Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research . Guide for the Use of the Uniform Data Set for Medical Rehabilitation . Buffalo, NY: State University of New York at Buffalo; March 1990. 57. Scheinberg LC, Feldman J, Ratzker P, et al. Self-assessment of neurological impairment in multiple sclerosis . Neurology . 1986;36( (suppl 1) ):284. Abstract.Crossref 58. Bijlsma JWJ, Huiskes CJAE, Kraaimaat FW, Vanderveen MJ, Huber-Bruning O. Relation between patients' own health assessment and clinical and laboratory findings in rheumatoid arthritis . J Rheumatol . 1991;18:650-653. 59. Lewinsohn PMW, Chaplin W, Barton R. Social competence and depression: the role of illusory self-perceptions . J Abnorm Psychol . 1980;89:203-212.Crossref 60. Schwartz CE, Cole BF, Vickrey B, Gelber RD. The Q-TWiST approach to assessing health-related quality of life in epilepsy. Qual Life Res. In press. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Archives of Neurology American Medical Association

Measuring Patient-Centered Outcomes in Neurologic Disease: Extending the Q-TWiST Method

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American Medical Association
Copyright
Copyright © 1995 American Medical Association. All Rights Reserved.
ISSN
0003-9942
eISSN
1538-3687
DOI
10.1001/archneur.1995.00540320026010
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Abstract

Abstract Background: Current clinical research and outcomes assessment on multiple sclerosis rely on an approach to disability measurement that is heavily influenced by ambulation. Not only is this strategy often insensitive to the clinical changes affected by pharmacotherapeutic or rehabilitative interventions but it also disregards the symptoms that patients seem to consider most enervating. We propose a new method for evaluating clinical interventions in terms of their impact on the symptoms of multiple sclerosis, side effects, parameters of exacerbation, and disease progression, while considering the patient's perspective. Methods: The extended Q-TWiST method yields an estimation of treatment trade-offs in terms of Quality-adjusted Time Without Symptoms and Toxicities (Q-TWiST). An illustration of this method is presented by using a hypothetical clinical trial of two treatments. The trade-offs between the two treatments are highlighted to facilitate treatment decision making by using individual patient importance weights. Conclusion: We discuss applications to other clinical research and other chronic diseases. References 1. Moss R. Toward the golden city . Agni . 1992;35:111. 2. Bauer C. From the patient's point of view . J Cogn Rehabil . 1992;10:9. 3. Fisk JD, Pontefract A, Ritvo P, Archibald CJ, Murray TJ. The impact of fatigue on patients with multiple sclerosis . Can J Neurol Sci . 1994;18( (suppl 1) ):79-83. 4. Noseworthy JH. Therapeutics of multiple sclerosis . Clin Neuropharmacol . 1991; 14:49-61.Crossref 5. Schumacher GA, Beebe G, Kibler RF, et al. Problems of experimental trials of therapy in multiple sclerosis: report by the Panel on the Evaluation of Experimental Trials of Therapy in Multiple Sclerosis . Ann N Y Acad Sci . 1965;122: 552-568.Crossref 6. Poser S. Management of patients with multiple sclerosis . In: Koestler JC, ed. Handbook of Clinical Neurology: Demyelinating Diseases . New York, NY: Elsevier Science Publishing Co Inc; 1985;3:147-186. 7. Trotter JL, Garvey WF. Prolonged effects of large-dose methylprednisolone infusion in multiple sclerosis . Neurology . 1980;30:702-708.Crossref 8. Lechtenberg R. Multiple Sclerosis Fact Book . Philadelphia, Pa: FA Davis Co Publishers; 1988. 9. Gelber RD, Goldhirsch A. A new endpoint for the assessment of adjuvant therapy in postmenopausal women with operable breast cancer . J Clin Oncol . 1986; 4:1772-1779. 10. Goldhirsch A, Gelber RD, Simes J, Glasziou P, Coates AS, for the Ludwig Breast Cancer Study Group. Costs and benefits of adjuvant therapy in breast cancer: a quality-adjusted survival analysis . J Clin Oncol . 1989;7:36-44. 11. Penn RD, Savoy SM, Corcos D, et al. Intrathecal baclofen for severe spinal spasticity . N Engl J Med . 1989;320:1517-1521.Crossref 12. Cohen RA, Fisher M. Amantadine treatment of fatigue associated with multiple sclerosis . Can J Neurol Sci . 1989;14:273-278. 13. Blaivas JG, Holland NJ, Geisser B, LaRocca N, Madonna M, Scheinberg L. Multiple sclerosis bladder: studies and care . Ann N Y Acad Sci . 1984;436:328-345.Crossref 14. Broman T. Management of patients with multiple sclerosis . In: Vinken PJ, Bruyn GW, eds. Handbook of Clinical Neurology, IX . New York, NY: Elsevier Science Publishing Co Inc; 1970:408-425. 15. Allshouse KD. Treating patients as individuals . In: Gerteis M, Edgman-Levitan S, Daley J, Delbanco TL, eds. Through the Patient's Eyes . San Francisco, Calif: Jossey-Bass Inc Publishers; 1993:19-44. 16. The Canadian Cooperative Multiple Sclerosis Study Group. The Canadian cooperative trial of cyclophosphamide and plasma exchange in progressive multiple sclerosis . Lancet . 1991;337:441-446. 17. Hauser SL, Dawson DM, Lehrich JR, et al. Intensive immunosuppression in progressive multiple sclerosis: a randomized, three-arm study of high-dose intravenous cyclophosphamide, plasma exchange, and ACTH . N Engl J Med . 1983;308:173-180.Crossref 18. Noseworthy JH, Vandervoot MK, Ebers GC, and the Canadian Cooperative Multiple Sclerosis Study Group. Acceptance of placebo-controlled trial design by progressive multiple sclerosis patients . Neurology . 1989;39:606-607. 19. Leo GJ, Rao SM. Effects of intravenous physostigmine and lecithin on memory loss in multiple sclerosis: report of a pilot study . J Neurol Rehabil . 1988;2: 123-129. 20. LaRocca NG. A rehabilitation perspective . In: Rao SM, ed. Neurobehavioral Aspects of Multiple Sclerosis . New York, NY: Oxford University Press Inc; 1990: 215-229. 21. Sullivan MJL, Dehoux E, Buchanan DC. An approach to cognitive rehabilitation in multiple sclerosis . Can J Rehabil . 1989;3:77-85. 22. Rao SM, Leo, GJ, Ellington LS, Nauertz T, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis, II: impact on employment and social functioning . Neurology . 1991;41:692-696.Crossref 23. Foley FW, Iverson J. Sexuality in multiple sclerosis . In: Kalb R, ed. The Family and Multiple Sclerosis . New York, NY: Demos Publications; 1992:63-82. 24. Rao SM, Leo GJ, Bernardin L, Unverzagt F. Cognitive dysfunction in multiple sclerosis, I: frequency, patterns, and prediction . Neurology . 1991;41:685-691.Crossref 25. Schwartz CE. Awareness and cognitive deficit in multiple sclerosis . Psychosom Med . 1993;55:130. Abstract. 26. Kurtzke JF. On the evaluation of disability in multiple sclerosis . Neurology . 1961; 11:686-694.Crossref 27. Kurtzke JF. Further notes on disability evaluation in multiple with scale modifications . Neurology . 1965;15:654-661.Crossref 28. Kurtzke JF. Rating neurologic impairment in multiple sclerosis: an Expanded Disability Status Scale (EDSS) . Neurology . 1983;33:1444-1452.Crossref 29. Kurtzke JF. Neuroepidemiology, II: assessment of therapeutic trials . Ann Neurol . 1986;19:311-319.Crossref 30. Pia Amato M, Fratiglioni L, Groppi C, Siracusa G, Amaducci L. Interrater reliability in assessing functional systems and disability on the Kurtzke scale in multiple sclerosis . Arch Neurol . 1988;45:746-748.Crossref 31. Noseworthy JH, Vandervoort MK, Wong CJ, Ebers GC, and the Canadian Cooperative MS Study Group. Interrater variability with the Expanded Disability Status Scale (EDSS) and Functional Systems (FS) in a multiple sclerosis clinical trial . Neurology . 1990;40:971-975.Crossref 32. Kurtzke JF. Disability rating scales in multiple sclerosis . Ann N Y Acad Sci . 1984;436:347-360.Crossref 33. The IFNB Multiple Sclerosis Study Group. Interferon beta-1b is effective in relapsing-remitting multiple sclerosis, I: clinical results of a multicenter, randomized, double-blind, placebo-controlled trial . Neurology . 1993;43:655-661.Crossref 34. Paty DW, Li DKB, the UBC MS/MRI Study Group, and the IFNB Multiple Sclerosis Study Group. Interferon beta-1 b is effective in relapsing-remitting multiple sclerosis, II: MRI analysis results of a multicenter, randomized, doubleblind, placebo-controlled trial . Neurology . 1993;43:662-667.Crossref 35. Tyler LE. Tests and Measurements . 2nd ed. Englewood Cliffs, NJ: Prentice-Hall International Inc; 1971:6. 36. Hohol MJ, Khoury SJ, Hafler DA, et al. Disease Steps in multiple sclerosis: a simple approach to classify patients and evaluate disease progression . Neurology . 1993;43:A203-A204. 37. Gelber RD, Lenderking WR, Cotton DJ, et al. Quality-of-life evaluation in a clinical trial of zidovudine therapy in patients with mildly symptomatic HIV infection . Ann Intern Med . 1992;116:961-966.Crossref 38. Gelber RD, Cole BF, Goldhirsch A. Comparing treatments using qualityadjusted survival: the Q-TWiST method. Am Stat. In press. 39. Cole BF, Gelber RD, Anderson KM. Parametric approaches to quality-adjusted survival analysis . Biometrics . 1994;50:621-631.Crossref 40. Glasziou PP, Simes RJ, Gelber RD. Quality-adjusted survival analysis . Stat Med . 1990;9:1259-1276.Crossref 41. Guyatt GH, Jaeschke R. Measurements in clinical trials: choosing the appropriate approach . In: Spilker B, ed. Quality of Life Assessments in Clinical Trials . New York, NY: Raven Press; 1990:37-46. 42. Nunnally JC. Psychometric Theory . 2nd ed. New York, NY: McGraw-Hill International Book Co; 1978:210-214. 43. Torrance GW, Thomas WH, Sackett DL. A utility maximization model for evaluation of health care programs . Health Serv Res . 1972;7;118-1133. 44. von Neumann J, Morgenstern O. The Theory of Games and Economic Behavior . New York, NY: John Wiley & Sons Inc; 1953. 45. Torrance GW, Boyle MH, Horwood SP. Application of multi-attribute utility theory to measure social preferences for health states . Operations Res . 1982;30: 1043-1069.Crossref 46. Rudick RA. Betaseron for multiple sclerosis: implications for therapeutics . Arch Neurol . 1994;51:125-127.Crossref 47. Burnham JA, Wright R, Dreisbach J, Murray RS. The effect of high-dose steroids on MRI gadolinium enhancement in acute demyelinating lesions . Neurology . 1991;41:1349-1354.Crossref 48. Poser CM. A numerical scoring system for the classification of multiple sclerosis . Acta Neurol Scand . 1979;60:100-111.Crossref 49. Radloff L. The CES-D scale: a self-report depression scale for research in the general population . Appl Psychol Measurement . 1977;1:385-401.Crossref 50. Coyle CP, Roberge JJ. The psychometric properties of the Center for Epidemiologic Studies—Depression Scale (CES-D) when used with adults with physical disabilities . Psychol Health . 1993;7:69-81.Crossref 51. Weiss W, Dambrosia JM. Common problems in designing therapeutic trials in multiple sclerosis . Arch Neurol . 1983;40:678-680.Crossref 52. Krupp LB, Alvarez LA, LaRocca NG, Scheinberg LC. Fatigue in multiple sclerosis . Arch Neurol . 1988;45:435-437.Crossref 53. Frankl DI. Multiple sclerosis . In: Umphred D, ed. Neurological Rehabilitation . 2nd ed. St Louis, Mo: Mosby—Year Book Inc; 1990:531-549. 54. Weiner HL, Mackin GA, Matsui M, et al. Double-blind pilot trial of oral tolerization with myelin antigens in multiple sclerosis . Science . 1993;259:1321-1324.Crossref 55. Bourdette DN, Prochazka AV, Mitchell W, Licari P, Burks J, and the VA Multiple Sclerosis Rehabilitation Study Group. Health care costs of veterans with multiple sclerosis: implications for the rehabilitation of MS . Arch Phys Med Rehabil . 1993;74:26-31. 56. Data Management Service of the Uniform Data System for Medical Rehabilitation and the Center for Functional Assessment Research . Guide for the Use of the Uniform Data Set for Medical Rehabilitation . Buffalo, NY: State University of New York at Buffalo; March 1990. 57. Scheinberg LC, Feldman J, Ratzker P, et al. Self-assessment of neurological impairment in multiple sclerosis . Neurology . 1986;36( (suppl 1) ):284. Abstract.Crossref 58. Bijlsma JWJ, Huiskes CJAE, Kraaimaat FW, Vanderveen MJ, Huber-Bruning O. Relation between patients' own health assessment and clinical and laboratory findings in rheumatoid arthritis . J Rheumatol . 1991;18:650-653. 59. Lewinsohn PMW, Chaplin W, Barton R. Social competence and depression: the role of illusory self-perceptions . J Abnorm Psychol . 1980;89:203-212.Crossref 60. Schwartz CE, Cole BF, Vickrey B, Gelber RD. The Q-TWiST approach to assessing health-related quality of life in epilepsy. Qual Life Res. In press.

Journal

Archives of NeurologyAmerican Medical Association

Published: Aug 1, 1995

References