ReQoL-10

ReQoL-10 in Routine Mental Health Outcome Measurement

The ReQoL-10 is the short form of the Recovering Quality of Life questionnaires, built so that a mental health service can ask the same ten questions at regular contacts and track recovery-focused quality of life alongside symptoms. For a health economist the ReQoL-10 matters because NHS England now names the ReQoL-10 in its recommended suite of outcome measures for community mental health services, so its scores can be collected routinely across whole services as well as inside trials. The total score runs on a scale of 0 to 40, and the developers publish a clinical cut-off of 24 or below and a reliable change of 5 points, so service data can be summarised as counts of people who improved reliably. The same questionnaire also carries the items of the ReQoL-UI, so a ReQoL-10 record can in principle be scored as a utility for a QALY calculation without a second questionnaire.

Development and the recovery framework behind the items

Keetharuth and colleagues published the ReQoL-10 and the longer ReQoL-20 together in 2018 in the British Journal of Psychiatry. They used qualitative methods to write the items and quantitative methods to cut them down, factor analysing data from more than 6,500 service users and using item response theory models to inform which items to keep. The authors framed the work as a response to criticism of generic measures such as the EQ-5D and SF-6D, which had faced doubts about their appropriateness for people with mental health difficulties.

The items rest on a recovery framework. Both versions contain positively and negatively worded items covering seven themes, namely activity, hope, belonging and relationships, self-perception, well-being, autonomy and physical health. The emphasis on hope, autonomy and a meaningful life reflects the recovery approach in mental health care, which values a life worth living alongside fewer symptoms, and in content the seven themes set the ReQoL-10 apart from the symptom scales more often used as outcomes in mental health economics.

The developers' site describes the measures as suitable for service users aged 16 and over and for use across mental health populations, including common mental health problems, severe and complex conditions and psychotic disorders, but not for people with dementia or learning disabilities. In the 2018 validation the authors reported acceptable internal consistency, test and retest reliability above 0.85, known-group differences, convergence with related measures and responsiveness over time for both versions.

Items, response levels and scoring

The ReQoL-10 has ten mental health items and one further item about physical health. The University of Sheffield scoring guide states that six of the ten mental health items are positively worded and four are negatively worded. Respondents describe their thoughts, feelings and activities over the last week, and each mental health item is answered on five levels that run between none of the time and most or all of the time.

Positively worded items score 0 for none of the time and 4 for most or all of the time, and negatively worded items are reversed so that they score 4 for none of the time and 0 for most or all of the time. The total is the sum of the ten mental health items.

$$S_{10} = \sum_{i \in P} x_i + \sum_{j \in N} (4-x_j)$$

where $S_{10}$ is the ReQoL-10 total, $P$ is the set of six positively worded items, $N$ is the set of four negatively worded items and $x$ is the response coded 0 for none of the time up to 4 for most or all of the time.

The total therefore runs between 0 and 40. The developers describe 0 as the poorest quality of life and 40 as the highest, so a rising score is good news, which is the opposite direction to the PHQ-9 and the GAD-7, where higher scores mean more severe symptoms.

The physical health item asks respondents to describe their physical health, meaning problems with pain, mobility, difficulties caring for themselves or feeling physically unwell, over the last week. The developers leave this item out of the total because, although physical health matters to the quality of life of mental health service users, physical health is distinct from mental health. The item is still collected, and the physical health item is one of the seven items that the ReQoL-UI uses to produce a utility.

Cut-off and reliable change for reading individual scores

The ReQoL Group's guidance on interpreting scores gives two reference points for the ReQoL-10. A score of 24 or below falls within the clinical range, and a score of 25 or above falls within the range of the general population. An increase of 5 points or more denotes reliable improvement, a decrease of 5 points or more denotes reliable deterioration and a smaller change is not counted as reliable. The guidance notes that these values may be refined as new data become available.

The two numbers answer different questions. Reliable change asks whether a change is larger than measurement error would plausibly produce, while the cut-off asks where a person's score sits relative to clinical and general population samples. Jacobson and Truax combined the two ideas in 1991, treating a change as clinically significant when it is statistically reliable and also carries the person across into the functional range. The guidance gives the same value, 5 points, for the minimal important difference. Classifying each person as improved or not discards smaller changes, so service comparisons often report mean change as well as counts.

Illustrative worked example of scoring and a cost per reliable improvement

All numbers here are illustrative. They show how a single ReQoL-10 is scored, how individual changes are classified with the published thresholds and how service data can feed a simple cost-effectiveness analysis in natural units.

1. Scoring one questionnaire. A respondent answers the six positively worded items at levels 3, 2, 3, 2, 3 and 2, so they contribute 3 + 2 + 3 + 2 + 3 + 2 = 15. The four negatively worded items are answered at levels 1, 2, 1 and 0, which reverse to 4 − 1 = 3, 4 − 2 = 2, 4 − 1 = 3 and 4 − 0 = 4, contributing 3 + 2 + 3 + 4 = 12. The total is 15 + 12 = 27, which lies in the general population range. The physical health answer is recorded but does not change the total.

2. Classifying change for four people. Person A scores 18 at assessment and 26 at discharge, a change of 26 − 18 = 8, which is a reliable improvement that also crosses the cut-off. Person B scores 20 and then 23, a change of 3, which is not reliable. Person C scores 23 and then 27, a change of 4 that crosses the cut-off but is not reliable. Person D scores 30 and then 24, a change of 24 − 30 = −6, which is a reliable deterioration.

3. Cost per reliable improvement in two services. Service X treats 200 people at a total cost of GBP 240,000, and 80 of them improve reliably, so the cost per reliable improvement is 240,000 / 80 = 3,000, or GBP 3,000. Service Y treats 200 similar people for GBP 280,000, and 100 improve reliably, so its average is 280,000 / 100 = 2,800, or GBP 2,800. The incremental cost of Y over X is 280,000 − 240,000 = 40,000 for 100 − 80 = 20 extra reliable improvements, which gives 40,000 / 20 = 2,000, or GBP 2,000 per extra person improved.

Service Y is more effective and its average cost per improvement is lower, but the figure that matters for choosing between the services is the incremental ratio of GBP 2,000. No accepted threshold exists for the value of one reliable improvement on the ReQoL-10, so the ratio cannot be compared with a cost per QALY threshold. Persons B and C also show what the classification hides, since both gained points and C now scores in the general population range, yet neither counts as improved.

Place in health economic evaluation

The ReQoL-10 total is a non-preference-based patient-reported outcome on a recovery scale. The total was not derived from a preference elicitation exercise, so the total cannot weight life years in a QALY, and a cost-utility analysis needs a separate step.

That step is the ReQoL-UI. The developers state that its six mental health items and one physical health item are contained in both the ReQoL-10 and the ReQoL-20, and that preference weights can be calculated from either version. A study or service that keeps item-level ReQoL-10 responses can therefore report a recovery score for clinicians and a utility for economists from the same form. A study that stored only totals cannot be rescored, because the utility depends on which items were answered at which level.

The ReQoL-10 total can still serve economic evaluation directly. The total can be the effectiveness measure in a cost-effectiveness analysis with natural units, as in the example above, or a secondary outcome reported beside EQ-5D QALYs to show effects the generic measure may miss.

Use in NHS services and routine data

The ReQoL-10 owes much of its reach to NHS policy. NHS England's commissioner guidance for adult community mental health rehabilitation services, published in June 2025, states that DIALOG, the ReQoL-10 and goal-based outcomes are the recommended suite for community mental health services. NHS England's 2024 implementation guidance on psychological therapies for severe mental health problems says services should be working towards routine use of the three measures, with goal-based outcomes and the ReQoL-10 completed at every clinical session where possible and appropriate, and with the frequency of measurement varying with the person's needs.

The developers' clinician note suggests the ReQoL-10 for weekly or regular monitoring and the ReQoL-20 for initial assessment, for the end of an intervention and for research. Routinely collected ReQoL-10 scores can serve as real-world data for evaluation, although a service summary is biased whenever the people with a missing final score differ from those who completed one.

Use is licensed. The University of Sheffield's licensing portal states that the ReQoL measures are managed exclusively by Oxford University Innovation on behalf of the University, which issues commercial licences and no-cost licences to the NHS and not-for-profit organisations.

How the ReQoL-10 differs from nearby measures

The ReQoL-10 sits among several mental health questionnaires that a health economist may meet in the same dataset. Each answers a different question, and the direction and use of the scores differ between them.

The ReQoL-10 and the ReQoL-20 measure the same construct, and the clinician note states that the first ten items of the ReQoL-20 form the ReQoL-10. The longer version adds items for precision and coverage at assessment and in research. The ReQoL-10 is also broader than a symptom scale, since the ReQoL-10 is meant for mental health service users across diagnoses, whereas the PHQ-9 and GAD-7 target depression and anxiety.

Limitations and common misreadings

Several errors recur when ReQoL-10 data are analysed or reported. Most come from treating the total as a measure of something other than recovery-focused quality of life.

• Total read as a utility. A score of 30 out of 40 is not a utility of 0.75. Only the ReQoL-UI algorithm, applied to item responses, gives a health state utility value.
• Physical item added to the total. The physical health item is excluded from the ReQoL-10 total by design, and adding it changes the scale and the meaning of the published thresholds.
• Thresholds treated as fixed. The cut-off of 24 and the reliable change of 5 come from the ReQoL Group's interpretation guidance, which says they may be refined. Score distributions and reliability also vary with the population and language version, and Grochtdreis and colleagues reported in 2023 a Cronbach's alpha of 0.83 for the German ReQoL-10, so thresholds set in English samples are approximations elsewhere.
• Direction confused with symptom scales. A fall in the ReQoL-10 is a worsening, while a fall in the PHQ-9 is an improvement, and pooled tables that mix the two invite sign errors.
• Improvement counts treated as the whole effect. Counting reliable improvements discards change below 5 points, so two services with the same count can differ in mean change, and a mean difference can hide how many people deteriorated.

Sources

• Grochtdreis T, König HH, Gallinat J, Konnopka A, Schulz H, Lambert M, Karow A, Dams J. Validation of the Recovering Quality of Life (ReQoL) questionnaires for patients with anxiety, obsessive-compulsive, stress-related, somatoform and personality disorders in Germany. Journal of Psychiatric Research. 2023;157:202-211. doi:10.1016/j.jpsychires.2022.11.032
• Jacobson NS, Truax P. Clinical significance: a statistical approach to defining meaningful change in psychotherapy research. Journal of Consulting and Clinical Psychology. 1991;59(1):12-19. doi:10.1037/0022-006X.59.1.12
• Keetharuth AD, Brazier J, Connell J, et al. Recovering Quality of Life (ReQoL): a new generic self-reported outcome measure for use with people experiencing mental health difficulties. British Journal of Psychiatry. 2018;212(1):42-49. doi:10.1192/bjp.2017.10. https://pmc.ncbi.nlm.nih.gov/articles/PMC6457165/
• Keetharuth AD, Rowen D, Bjorner JB, Brazier J. Estimating a preference-based index for mental health from the Recovering Quality of Life measure: valuation of Recovering Quality of Life Utility Index. Value in Health. 2021;24(2):281-290. doi:10.1016/j.jval.2020.10.012
• NHS England. Commissioner guidance for adult community mental health rehabilitation services. Published 9 June 2025, updated 18 June 2025. https://www.england.nhs.uk/long-read/commissioner-guidance-adult-community-mental-health-rehabilitation-services/
• NHS England. Psychological therapies for severe mental health problems: implementation guidance 2024. Published 22 April 2024. https://www.england.nhs.uk/long-read/implementation-guidance-2024-psychological-therapies-for-severe-mental-health-problems/
• ReQoL Group. Interpreting ReQoL scores. University of Sheffield. https://sheffield.ac.uk/sites/default/files/2022-04/InterpretReQoLscores.pdf
• ReQoL (University of Sheffield). Overview. Accessed 17 October 2026. https://www.reqol.org.uk/p/overview.html
• ReQoL (University of Sheffield). Scoring. Accessed 17 October 2026. https://www.reqol.org.uk/p/scoring.html
• ReQoL (University of Sheffield). ReQoL-UI preference weights. Accessed 17 October 2026. https://www.reqol.org.uk/p/reqol-ui-preference-weights.html
• University of Sheffield. ReQoL clinician note. https://sheffield.ac.uk/sites/default/files/2022-04/cliniciannote.pdf
• University of Sheffield. ReQoL-10 scoring guide, version 0.2. https://sheffield.ac.uk/sites/default/files/2022-04/ReQoL10_Scoring_Guide_v0.2.pdf
• University of Sheffield Online Licensing Portal. ReQoL, Recovering Quality of Life. Accessed 17 October 2026. https://licensing.sheffield.ac.uk/product/ReQOL