Abstract
Aim
This study aimed to compare the 12‐item and 36‐item versions of the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 using longitudinal data from community mental health outreach service users.
Methods
Using data from Tokorozawa City mental health outreach service users in Japan, total and domain WHODAS‐12 and WHODAS‐36 scores were compared. First, we examined score‐change differences by domain at the start of outreach services (T1) and 1 year later (T2) for each version. Next, we compared differences between the two versions using Pearson's correlation, Wilcoxon signed‐rank test, and Bland–Altman analysis.
Results
Among 20 participants, total scores and scores of some domains (i.e., cognition, getting along, life activities, and participation) were significantly lower at T2 than at T1 on both versions (p < 0.010). WHODAS‐36 scores were significantly lower at T2 than at T1 for the self‐care domain (p = 0.018). Except for self‐care, strong correlations were found between scores from the two versions (p < 0.001). In the Wilcoxon signed‐rank test and Bland–Altman analysis, we found significant differences between the scores of the two versions in the mobility, self‐care, and participation domains. There were no significant differences in the distribution or systematic errors between the two versions in scores for the other domains or total score.
Conclusion
We found strong positive correlations between WHODAS‐12 and WHODAS‐36 total scores with no statistical differences between them. For some domains, differences in distribution and systematic errors were found.
Keywords: community mental health, comparison, longitudinal study, outreach, schizophrenia (clinical), WHODAS 2.0
This study aimed to compare the 12‐item and 36‐item versions of the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 using longitudinal data from community mental health outreach service users. We found strong positive correlations between WHODAS‐12 and WHODAS‐36 total scores with no statistical differences between them. For some domains, differences in distribution and systematic errors were found.
1. INTRODUCTION
In community mental health outreach, assessment of service users is important for identifying user needs, setting priorities, and evaluating the effectiveness of services. The World Health Organization Disability Assessment Schedule (WHODAS) 2.0 is an internationally recommended tool for assessing disability and functional impairment. 1 , 2 This scale is based on the conceptual framework of the International Classification of Functioning, Disability, and Health. 3 WHODAS 2.0 has been translated into various languages and is used around the world. 4 , 5 In the field of psychiatry, WHODAS 2.0 has been reported to be a practical and valid means of assessing functioning among both critically ill patients and community populations with common mental health problems. 6 , 7 , 8 , 9
WHODAS 2.0 has several versions. The full version consists of 36 items (WHODAS‐36). The short version consists of 12 items (WHODAS‐12). WHODAS 2.0 includes three response types: self‐administered, interviewer‐administered, and proxy‐administered questionnaires. 2 While it is important for service users to evaluate the outcomes of service use themselves, 10 a systematic review has found a high correlation between the self‐administered and proxy‐administered versions of WHODAS 2.0. 11
Community mental health outreach professionals often care for community residents with various characteristics, including hikikomori and untreated problems as well as severe mental illness. In the community care setting, some service users cannot answer the questionnaires by themselves due to severe symptoms. Service providers might be unable to spend sufficient time asking them about multiple questionnaire items in order to prioritize treatment or build a therapeutic relationship. In this context, proxy‐administered WHODAS‐12 might be a realistic option in clinical settings. Several studies have compared the 12‐item and 36‐item versions of WHODAS 2.0 among people with physical disabilities or autism. 12 , 13 , 14 , 15 However, no studies have been conducted on individuals with mental illness or suspected mental illness. In this study, a preliminary investigation with a small sample size, we compared the 12‐item and 36‐item versions of the proxy‐administered WHODAS 2.0 using Tokorozawa City mental health outreach users' data in Japan.
2. METHODS
2.1. Study design and participants
Using the clinical data from Tokorozawa City mental health outreach service users in Japan, we compared the total score and scores for each domain of the 12‐item and 36‐item versions of WHODAS 2.0. This team consists of multidisciplinary professionals and assists community residents with various mental health issues, including people with severe mental illness and people who have untreated or undiagnosed problems. For more information, refer Iwanaga et al. 16 This team used the WHODAS‐36 at the start of the service (T1) and approximately 1 year later (T2) for new registered users between October 2, 2018, and April 26, 2021, for clinical assessment, not for this study. Of the 37 registered users, 32 were assessed using WHODAS‐36 at T1. We analyzed data from 20 users with WHODAS‐36 scores at both T1 and T2. When there was insufficient information or lack of contact with the service user, WHODAS‐36 could not be used. At T2, WHODAS‐36 was not used among those who ended service use in less than 1 year (n = 5). The Tables S1 and S2 shows the characteristics of the study participants and others. No exclusion criteria were established. This study was approved by the Research Ethics Committee of the National Center of Neurology and Psychiatry (no. A2023‐024).
2.2. Measures
2.2.1. WHODAS 2.0
We obtained WHODAS‐36 scores 17 , 18 , 19 at T1 and T2. This score was generated with proxy ratings by multiple outreach staff members. WHODAS‐36 consists of six domains (1): cognition, (2) mobility, (3) self‐care, (4) getting along with people, (5‐1) life activities (household activities), (5‐2) life activities (work or school activities), and (6) participation. 2 , 18 Each item has five response categories (1 = none, 2 = mild, 3 = moderate, 4 = severe, 5 = extreme or cannot do). According to the official guideline's recommendation, 2 missing items were complimented with mean score across all items within the domain. WHODAS‐12 scores were calculated using WHODAS‐36 scores as shown in Table 1. Total scores were calculated as the sum of scores across domains. Total and domain scores for both versions were converted to a range of 0 (no disability) to 100 (full disability).
TABLE 1.
Compatible WHODAS‐12 and WHODAS‐36 items.
| WHODAS‐12 | WHODAS‐36 | Domain |
|---|---|---|
| S1 | D2.1 | Domain 2: Mobility |
| S2 | D5.1 | Domain 5: Life activities (household activities) |
| S3 | D1.4 | Domain 1: Cognition |
| S4 | D6.1 | Domain 6: Participation |
| S5 | D6.5 | Domain 6: Participation |
| S6 | D1.1 | Domain 1: Cognition |
| S7 | D2.5 | Domain 2: Mobility |
| S8 | D3.1 | Domain 3: Self‐care |
| S9 | D3.2 | Domain 3: Self‐care |
| S10 | D4.1 | Domain 4: Getting along with people |
| S11 | D4.2 | Domain 4: Getting along with people |
| S12 | D5.5 | Domain 5: Life activities (work or school activities) |
Abbreviation: WHODAS, The World Health Organization Disability Assessment Schedule.
2.2.2. Demographic and clinical characteristics of participants
The following data from assessment records at the start of outreach service use were included: sex, age, living situation, history of psychiatric consultation, diagnosis based on the International Classification of Diseases 10th Revision, hikikomori status (being withdrawn at home for more than 6 months without going to work or school and having little contact with people other than family members).
2.3. Statistical analysis
First, the Wilcoxon signed‐rank test was used to examine the differences in scores between WHODAS‐36 and WHODAS‐12 at T1 and T2. Second, Pearson's correlation coefficient between scores of each version at each time point was calculated; Wilcoxon signed‐rank test and Bland–Altman analysis were conducted to investigate differences in the distribution and systematic errors between WHODAS‐36 and WHODAS‐12. These analyses were performed for T1 scores only, T2 scores only, and T1 minus T2 scores. Statistical significance was set at 0.05. All analyses were conducted using R statistical software. The exactRankTests and blandr packages were used for data analysis.
3. RESULTS
This study included 20 participants (average age ± SD: 41.0 ± 20.6 years; male: n = 8; living alone: n = 6). There were 15 users with a history of psychiatric consultation and 5 users were admitted to a psychiatric hospital in the past 12 months. The most common diagnosis (n = 6) was schizophrenia. Four users had an unknown or no psychiatric diagnosis. Twelve people were hikikomori at the start of the outreach service use (Table S1).
Table 2 shows total and domain WHODAS‐12 and WHODAS‐36 scores. Total scores (p = 0.001) and the following domain scores were significantly lower at T2 than at T1 on both versions: cognition, getting along with people, total life activities, household activities, and participation (p ≤ 0.013). WHODAS‐36 scores at T2 were also significantly lower than at T1 for the self‐care domain (p = 0.018). In the self‐care domain, there was a significant difference between time points in the WHODAS‐36 only (p = 0.018). For each item in this domain, significant differences were found in item D3.4, which was not included in the WHODAS‐12 (Table S2).
TABLE 2.
Total and domain WHODAS‐12 and WHODAS‐36 scores at the start of community mental health outreach service use (T1) and 1 year later (T2) (n = 20). a
| WHODAS‐12 | WHODAS‐36 | |||||
|---|---|---|---|---|---|---|
| T1 | T2 | p b | T1 | T2 | p b | |
| Total score | ||||||
| Mean ± SD | 53.0 ± 22.9 | 35.6 ± 10.0 | 0.001* | 52.3 ± 21.7 | 36.6 ± 9.6 | 0.001* |
| Median | 48.3 | 35.6 | 45.0 | 36.1 | ||
| Domain 1: Cognition | ||||||
| Mean ± SD | 56.5 ± 30.7 | 33.5 ± 13.5 | 0.004* | 55.3 ± 26.3 | 35.7 ± 9.7 | 0.005* |
| Median | 55.0 | 30.0 | 48.3 | 33.3 | ||
| Domain 2: Mobility | ||||||
| Mean ± SD | 44.0 ± 28.4 | 33.0 ± 21.5 | 0.109 | 37.2 ± 21.1 | 30.4 ± 15.8 | 0.236 |
| Median | 40.0 | 20.0 | 28.0 | 20.0 | ||
| Domain 3: Self‐care | ||||||
| Mean ± SD | 33.5 ± 22.8 | 23.0 ± 7.3 | 0.063 | 39.0 ± 22.2 | 26.3 ± 9.1 | 0.018* |
| Median | 20.0 | 20.0 | 35.0 | 20.0 | ||
| Domain 4: Getting along with people | ||||||
| Mean ± SD | 61.5 ± 30.3 | 39.8 ± 18.7 | 0.001* | 61.7 ± 27.9 | 44.5 ± 19.2 | 0.013* |
| Median | 60.0 | 40.0 | 54.0 | 48.0 | ||
| Domain 5: Life activities (total) c | ||||||
| Mean ± SD | 48.5 ± 28.9 | 29.5 ± 14.3 | 0.002* | 49.0 ± 29.4 | 31.0 ± 15.2 | 0.003* |
| Median | 45.0 | 30.0 | 48.8 | 27.5 | ||
| Domain 5: Life activities (household activities) | ||||||
| Mean ± SD | 63.0 ± 32.0 | 39.0 ± 17.7 | 0.003* | 63.0 ± 31.8 | 42.2 ± 18.7 | 0.009* |
| Median | 60.0 | 40.0 | 57.5 | 42.5 | ||
| Domain 5: Life activities (work or school activities) | ||||||
| Mean ± SD | 34.0 ± 44.1 | 20.0 ± 25.1 | 0.186 | 35.0 ± 43.6 | 19.8 ± 23.9 | 0.093 |
| Median | 0.0 | 10.0 | 0.0 | 10.0 | ||
| Domain 6: Participation | ||||||
| Mean ± SD | 73.8 ± 29.4 | 55.0 ± 23.5 | 0.005* | 63.4 ± 26.3 | 46.8 ± 17.3 | 0.004* |
| Median | 85.0 | 55.0 | 66.3 | 43.8 | ||
Abbreviations: SD, standard deviation; WHODAS, The World Health Organization Disability Assessment Schedule.
All total and domain scores were converted to a range of 0 (no disability) to 100 (full disability).
Differences between scores at T1 and T2 were examined using the Wilcoxon signed‐rank test.
Life activities score (total) was calculated by combining the scores of Life activities (household activities) and Life activities (work and school activities) on a 100‐point scale.
p < 0.05.
Table 3 shows the result of Pearson's correlation analysis for WHODAS‐12 and WHODAS‐36 scores. For total score, there were strong positive correlations between WHODAS‐12 and WHODAS‐36 for T1, T2, and T1–T2 scores (r ≥ 0.915, p < 0.001). For domains except for self‐care, there were strong positive correlations between scores from the two versions. In Tables 4 and 5, for total score, there were no significant differences between the two versions. For each domain, there were significant differences between the scores from the two versions in the mobility, self‐care, and participation domains at T1 and T2, while there were no differences for T1–T2 scores.
TABLE 3.
Pearson's correlation between WHODAS‐12 and WHODAS‐36 scores at the start of community mental health outreach service use (T1) and 1 year later (T2) (n = 20).
| T1 | T2 | T1–T2 | ||||
|---|---|---|---|---|---|---|
| Correlation coefficient | p | Correlation coefficient | p | Correlation coefficient | p | |
| Total score | 0.981 | <0.001* | 0.915 | <0.001* | 0.979 | <0.001* |
| Domain 1: Cognition | 0.952 | <0.001* | 0.754 | <0.001* | 0.922 | <0.001* |
| Domain 2: Mobility | 0.977 | <0.001* | 0.951 | <0.001* | 0.951 | <0.001* |
| Domain 3: Self‐care | 0.894 | <0.001* | 0.597 | 0.005* | 0.920 | <0.001* |
| Domain 4: Getting along with people | 0.944 | <0.001* | 0.821 | <0.001* | 0.860 | <0.001* |
| Domain 5: Life activities (total) a | 0.959 | <0.001* | 0.821 | <0.001* | 0.937 | <0.001* |
| Domain 5: Life activities (household activities) | 0.959 | <0.001* | 0.827 | <0.001* | 0.906 | <0.001* |
| Domain 5: Life activities (work or school activities) | 0.970 | <0.001* | 0.910 | <0.001* | 0.952 | <0.001* |
| Domain 6: Participation | 0.926 | <0.001* | 0.838 | <0.001* | 0.813 | <0.001* |
Abbreviation: WHODAS, The World Health Organization Disability Assessment Schedule.
Life activities score (total) was calculated by combining the scores of Life activities (household activities) and Life activities (work and school activities) on a 100‐point scale.
p < 0.05.
TABLE 4.
Differences between WHODAS‐12 and WHODAS‐36 scores at the start of community mental health outreach service use (T1) and 1 year later (T2), based on the Wilcoxon signed‐rank test (n = 20).
| p at T1 | p at T2 | p at T1–T2 | |
|---|---|---|---|
| Total score | 0.837 | 0.425 | 0.145 |
| Domain 1: Cognition | 0.521 | 0.306 | 0.220 |
| Domain 2: Mobility | 0.002* | 0.246 | 0.087 |
| Domain 3: Self‐care | 0.037* | 0.066 | 0.174 |
| Domain 4: Getting along with people | 0.616 | 0.109 | 0.242 |
| Domain 5: Life activities (total) a | 0.820 | 0.435 | 0.474 |
| Domain 5: Life activities (household activities) | 0.797 | 0.238 | 0.368 |
| Domain 5: Life activities (work or school activities) | >0.999 | >0.999 | 0.781 |
| Domain 6: Participation | 0.001* | 0.009* | 0.374 |
Abbreviation: WHODAS, The World Health Organization Disability Assessment Schedule.
Life activities score (total) was calculated by combining the scores of life activities (household activities) and life activities (work and school activities) on a 100‐point scale.
p < 0.05.
TABLE 5.
Comparison of WHODAS‐12 and WHODAS‐36 scores at the start of community mental health outreach use (T1) and 1 year later (T2) in Bland–Altman analyses (n = 20).
| T1 | T2 | T1–T2 | ||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Bias | 95% CI of bias | Limits of agreement | Bias | 95% CI of bias | Limits of agreement | Bias | 95% CI of bias | Limits of agreement | ||||
| Upper | Lower | Upper | Lower | Upper | Lower | |||||||
| Total score | 0.694 | −1.400 to 2.788 | 9.463 | −8.076 | −0.920 | −2.827 to 0.988 | 7.067 | −8.907 | 1.613 | −0.516 to 3.743 | 10.533 | −7.306 |
| Domain 1: Cognition | 1.667 | −3.396 to 5.730 | 20.276 | −17.943 | −2.167 | −6.318 to 1.985 | 15.219 | −19.553 | 3.333 | −2.188 to 8.855 | 26.456 | −19.790 |
| Domain 2: Mobility | 6.800 | 2.610 to 10.990* | 24.349 | −10.749 | 2.600 | −1.219 to 6.419 | 18.592 | −13.392 | 4.200 | −0.543 to 8.943 | 24.062 | −15.662 |
| Domain 3: Self‐care | −5.500 | −10.355 to −0.645* | 14.834 | −25.834 | −3.333 | −6.849 to 0.182 | 11.391 | −18.057 | −2.167 | −6.279 to1.946 | 15.057 | −19.390 |
| Domain 4: Getting along with people | −0.200 | −4.882 to 4.482 | 19.406 | −19.806 | −4.683 | −9.971 to 0.604 | 17.466 | −24.828 | 4.483 | −2.179 to 11.146 | 32.386 | −23.420 |
| Domain 5: Life activities (total) a | −0.500 | −4.401 to 3.401 | 15.837 | −16.837 | −1.458 | −5.599 to 2.682 | 15.883 | −18.800 | 0.958 | −3.385 to 5.302 | 19.148 | −17.232 |
| Domain 5: Life activities (household activities) | 0.000 | −4.295 to 4.295 | 17.986 | −17.986 | −3.167 | −8.196 to 1.862 | 17.895 | −24.228 | 3.167 | −2.854 to 9.187 | 28.379 | −22.046 |
| Domain 5: Life activities (work or school activities) | −1.000 | −6.013 to 4.013 | 19.995 | −21.995 | 0.250 | −4.639 to 5.139 | 20.727 | −20.227 | −1.25 | −6.771 to 4.271 | 21.870 | −24.370 |
| Domain 6: Participation | 10.381 | 5.168 to 15.594* | 32.214 | −11.452 | 8.185 | 2.073 to 14.296* | 33.779 | −17.410 | 2.196 | −4.920 to 9.313 | 32.001 | −27.608 |
Abbreviation: CI, confidence interval.
Life activities score (total) was calculated by combining the scores of life activities (household activities) and life activities (work and school activities) on a 100‐point scale.
p < 0.05.
4. DISCUSSION
This study compared the 12‐item and 36‐item versions of WHODAS 2.0 using longitudinal data from community mental health outreach service users. Total scores at T2 were significantly lower than at T1 for both versions, indicating functional improvement. For total score, there were strong positive correlations between the two versions; this study found no statistical differences. For some domains, although the analysis showed a high correlation between the scores from the two versions, differences in the distribution and systematic errors were found.
For total score, WHODAS‐12 might be used instead of WHODAS‐36. The findings are consistent with previous studies among patients with physical disabilities 12 , 13 , 14 and autism spectrum disorder. 15 WHODAS‐12 might be sufficient for measuring the overall function of community mental health outreach service users.
Some WHODAS‐12 domains showed poor agreement with WHODAS‐36, which was consistent with previous studies among patients with physical disabilities. 13 , 14 For domain‐specific scores, the WHODAS‐12 would be inadequate. Particularly, in the self‐care domain, the change in items not included in the WHODAS‐12 was greater than the change in items included in the WHODAS‐12. Previous studies in other populations have confirmed the appropriateness of the WHODAS‐12 factor structure. 13 , 15 However, future studies with larger samples are required to determine whether the same results would be obtained among community mental health outreach users.
5. LIMITATIONS
First, this preliminary study used data from one outreach team and the sample size was small, which might have resulted in substantial sampling error and inadequate statistical power. Second, more than half of the participants were hikikomori. It is necessary to examine whether proxy‐administered ratings by multiple staff members for outreach users, including hikikomori, are also highly correlated with the self‐administered version, as in previous studies. 11 Third, when drawing conclusions about the effectiveness of outreach services, analyses adjusting for confounding factors (e.g., clinical information) are needed. Fourth, detailed analyses with larger samples would require determining which items affect domain scores.
6. CONCLUSION
Total WHODAS‐12 and WHODAS‐36 scores were highly correlated with no distributional differences or systematic errors. However, these were found for some domain scores. Further research with more rigorous methods is needed to confirm the findings of this study.
AUTHOR CONTRIBUTIONS
MI was primarily responsible for the study design, conducted the statistical analysis, and wrote the draft of the manuscript. SY, SS, KU, KN, EN, MS, YS, and CF managed data collection. All authors contributed to the study design and interpretation of the results. All authors approved the final version of the manuscript.
FUNDING INFORMATION
This work was supported by Health and Labour Sciences Research Grants titled “Development of implementation methods and systems for early intervention of mental health services in individual communities” (no. 19GC1015) (Takahiro Nemoto) and “Development of a mental health service system for comprehensive case management in psychiatric institutions” (no. 22GC0301) (Sosei Yamaguchi). This work is also supported by Japan Society for the Promotion of Science (JSPS) KAKENHI (no. JP23H00905) (Sosei Yamaguchi).
CONFLICT OF INTEREST STATEMENT
The authors declare no conflict of interest.
ETHICS STATEMENT
Approval of the Research Protocol by an Institutional Reviewer Board: This study was approved by the Research Ethics Committee of the National Center of Neurology and Psychiatry (no. A2023‐024).
Informed Consent: Prior to initiating the study, we created an official webpage informing participants about the intended use of service record data related to their background characteristics and services provided. In addition, the opportunity to refuse participation was guaranteed.
Registry and the Registration No. of the Study/Trial: N/A.
Animal Studies: N/A.
Supporting information
Tables S1–S2.
ACKNOWLEDGMENTS
The authors would like to thank the study participants for their cooperation.
Iwanaga M, Yamaguchi S, Sato S, Usui K, Nakanishi K, Nishiuchi E, et al. Comparison of the 12‐item and 36‐item versions of the World Health Organization Disability Assessment Schedule (WHODAS) 2.0 using longitudinal data from community mental health outreach service users. Neuropsychopharmacol Rep. 2024;44:457–463. 10.1002/npr2.12426
DATA AVAILABILITY STATEMENT
Not all data are freely accessible because no informed consent was given by the participating agencies for open data sharing. However, the data are available from the corresponding author upon reasonable request, following approval by the Research Ethics Committee of the National Center of Neurology and Psychiatry.
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Associated Data
This section collects any data citations, data availability statements, or supplementary materials included in this article.
Supplementary Materials
Tables S1–S2.
Data Availability Statement
Not all data are freely accessible because no informed consent was given by the participating agencies for open data sharing. However, the data are available from the corresponding author upon reasonable request, following approval by the Research Ethics Committee of the National Center of Neurology and Psychiatry.