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Pittock et al1 conclude in a provocative title that quality of life (QOL) is favorable for most patients with multiple sclerosis (MS). This conclusion is in striking contrast to population-based studies reporting that 45% of MS patients were unemployed due to their disease and 37% experienced a decline in their standards of living.2 - 3 The conclusion is based on the finding that patients’ Short Form-36 scores were comparable to that of the US population on 3 of 4 mental health scales, even though they reported lower scores on 4 of 8 Short Form-36 scales.
The absence of a decrease in mental health scores in patients who face increasing functional limitations is a rather common finding in questionnaire studies and explained by a phenomenon called response shift.4 Response shift occurs due to changes in definitions and reference standards for the QOL domains. For example, the impact of disease on social interactions (Short Form-36 social functioning) depends considerably on the definition of social interactions. Patients who are no longer able to go to concerts with friends may report lower scores on the Short Form-36 social functioning scale when they define social interactions as going with friends to concerts, than when their definition is having a supportive relationship with a close friend. When they have changed their definitions from the former to the latter, they may report comparable social functioning scores over time, even though their actual social activities are considerably adapted to their physical limitations.
Changing definitions and reference standards enables patients to maintain mental health and positive outlooks in situations of increasing functional limitations.5 Although Pittock et al1 have performed a clear and methodologically sound study, their conclusion disregards the impact of chronic diseases on patients’ lives.
Correspondence: Dr Janssens, Erasmus MC, University Medical Center Rotterdam, Department of Public Health, PO Box 1738, 3000 DR, the Netherlands (a.janssens@erasmusmc.nl).
Country-Specific Mortality and Growth Failure in Infancy and Yound Children and Association With Material Stature
Use interactive graphics and maps to view and sort country-specific infant and early dhildhood mortality and growth failure data and their association with maternal
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