Assessing Psychological Distress in Psychiatric Patients: Validation of the Talbieh Brief Distress Inventory Michael Ritsner, Ilan Modai, and Alexander Ponizovsky The present study examined the psychometric prop- erties of the Talbieh Brief Distress Inventory (TBDI), a 24-item self-report instrument used to measure psy- chological distress, for use in psychiatric patients. A case-control and partly longitudinal design was used to test the TBDI among 431 psychiatric outpatients and inpatients and 197 gender- and age-matched non- patients. All respondents were interviewed using the ICD-10 Symptom Checklist, and patients additionally with psychopathology rating scales. Internal consis- tency of the TBDI distress index was 0.92. A cutoff of 2.0 was associated with 96% sensitivity and 56% spec- ificity. Mean TBDI scores were significantly lower for nonpatients than for both outpatients and inpatients, and for schizophrenic patients compared with pa- tients suffering from schizoaffective/mood disorders and from neurotic/personality disorders. The TBDI shows good capacity to discriminate levels and symp- toms of distress between control subjects and men- tally ill patients. The TBDI is a brief, valid, and useful tool for stress-related research that allows compari- son of the psychological responsiveness of distinct patients and groups of patients and facilitates assess- ment of distress levels across cultural or language barriers. Copyright 2002, Elsevier Science (USA). All rights re- served. P SYCHOLOGICAL DISTRESS experienced by patients suffering from mental disorders had been neglected for a long time. Recently, this factor has attracted attention because of its rele- vance for compliance, quality of life, and predic- tion of treatment outcome and planning of appro- priate treatment. 1-3 Psychological distress is described as a reaction of an individual to external and in- ternal stresses and has been characterized by a mixture of psychological symptoms, such as poor self-esteem, hopelessness, helplessness, dread, confused thinking, sadness, anxiety, and psycho- physiological symptoms. 4 Few investigators ac- knowledge that the afflicted person is not identical with the disorder and that mentally ill individuals may react psychologically to life events such as their own disease. 5-8 Moreover, subjective reac- tions to the same psychopathological symptoms may differ considerably in their expression and duration among different patients. 9 The theoretical model underlying the present study suggests that two different realities coexist within the mentally ill individual: one external (clinical) and an- other internal (psychological). The clinical reality is based on psychopathological symptoms that can be ascertained by a clinician using direct observation and interview utilizing observer-based scales, while the psychological reality, expressing the subjective expe- rience of the disease or suffering, may be accessible only through the patient’s self-report. Thus, the dis- crepancy between the two types of assessments has considerably deeper origins than the problem of valid- ity and reliability of the patient’s self-reports. 10 The clinical relevance of the subjective experi- ence of mental disorders has been reported in a few studies, which showed that pervasive distress may affect the course of illness, symptom expres- sion, and levels of social relationships and adapta- tion. 11-14 Although self-reported distress highly correlates to subjective measures of depression, 15 conceptually and empirically, distress is distinct from depression and depressive symptoms. Apart from depressive symptoms, distress incorporates others nonspecific psychological manifestations, has stronger relations with common psychosocial factors, and tends to be milder and more transient than depression. 16 Several validated self-report questionnaires for measuring psychological distress have been devel- oped. Among others, the Symptom Checklist-90 17 and its abridged version, the Brief Symptom In- ventory (BSI), 18 and the Psychiatric Epidemiolog- ical Research Interview-Demoralization Scale (PERI-D) 4 have often been used in general popu- lation studies. 19 The BSI can measure both general psychological discomfort and distinct manifesta- tions of psychopathology, but is too time-consum- From the Institute for Psychiatric Studies, Sha’ar Menashe Mental Health Center, Hadera, Israel; and the Bruce Rappa- port Faculty of Medicine, Technion, Haifa, Israel. Supported in part by the Israeli Ministry of Immigrant Ab- sorption (A.P.). Address reprint requests to Michael Ritsner, M.D., Ph.D., Mobile Post Hefer 38814, Sha’ar Menashe Mental Health Cen- ter, Hadera, Israel. Copyright 2002, Elsevier Science (USA). All rights reserved. 0010-440X/02/4303-0015$35.00/0 doi:10.1053/comp.2002.30800 Comprehensive Psychiatry, Vol. 43, No. 3 (May/June), 2002: pp 229-234 229