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We developed the MMSE to solve a clinical problem on a geriatric psychiatric inpatient service. The diagnoses of patients on our unit included depression, dementia, delirium, and occasional late-life schizophrenia. We needed a practical quantitative cognitive exam in order to aide clinicians in determining the severity of cognitive impairment ranging from mild to severe and to document improvement or decline.
At the time, Susan was a psychiatry resident rotating on the geriatric psychiatric unit where I (Marshal) was a junior attending. Always a perfectionist, she was not happy when I repeatedly asked for cognitive information that she had not asked about. So she asked me to write down all the items that I wanted her to include.
Over the years, students and other users made many suggestions about how to improve the MMSE. There was a need to clarify the instructions so that certain tasks were administered; there was a need for phrases that were more easily translated into other languages; and users requested multiple forms in order to minimize practice effects with serial administration. In addition, we had long wanted to develop a shorter version that could be given very quickly in busy clinical settings, and also a longer version that would eliminate ceiling effects. We wanted this longer version to be more sensitive than the original MMSE to disorders of executive function and to the kinds of memory impairment found in mild cognitive impairment.
The MMSE-2 Standard Version scores are equivalent to the original MMSE scores. We took care that subjects tested during development scored the same, regardless of whether they were given the original MMSE or the MMSE-2 Standard Version. Longitudinal studies currently underway can switch to the new version without any adjustment to scores. The original, unrevised MMSE is still available if users do not want to change to the revised versions.
Marshal takes flute lessons and is trying to improve his photography. Susan enjoys gardening and reading spy novels, biographies, Jane Austen, and Patrick O’Brian. She has a new job at the University of Miami School of Medicine with a joint appointment in psychiatry and in the Hussman Institute for Human Genomics. We both like to write and watch old movies.
Bob Smith: Absolutely. There has always been an issue of test security. People who steal tests are not only costing us money, but they’re also harming the industry and depriving the test authors of royalties. Having a stolen test floating around is potentially quite harmful.
Cathy Smith: We have two employees who regularly surf the web, looking for people who are reproducing our content without permission. They’ve gotten very good at catching these folks and getting them to delete any of our content off their Web sites.
Bob Smith: On every order we send out, there’s a statement on our Order Form that says the Customer agrees to abide by the rules and not reproduce our products without written permission.
Bob Smith: Usually, a letter or phone call asking them to stop will do. Most people ultimately want to do the right thing.
Bob Smith: We have hired attorneys in numerous situations to protect our copyrights, and we will continue to do so.
Bob Smith: I agree with the verdict. The student was stealing.
Bob Smith: Don’t do it. Our products are very useful and they are valuable products that are used to help people make better decisions. By infringing on the copyright, you could help to invalidate the measure, causing harm not only to the instrument, but to the test publishing industry, the authors, and most importantly, to the client/patient.
PAR’s position is that Customers may not release copyrighted and confidential material to individuals not professionally qualified to obtain, review, or interpret them. PAR’s instruments are trade secrets protected by intellectual property laws, including copyright and trade secret laws. Their usefulness and validity would be greatly compromised if they were available to the general public.
Cathy Smith: All materials in our catalog and on our Web site are protected by copyright. This applies to all Web site information, testing products, and everything associated with them.
Submitting a completed PAR Qualification Form and/or placing an order to purchase materials from PAR implies your acceptance of these terms and conditions.
Bob Smith: No, our products are not for rent. We do encourage the use of our proprietary tests in research projects. However, we require that a formal written permission agreement be obtained from PAR prior to beginning the work if a modified version or only a portion of test is needed.
Bob Smith: It has always been this way in this industry. Test products must be kept secure. Our products are highly restricted and will stay that way.
Bob Smith: When PAR first got started, the majority of the products we sold were developed externally by authors and sent to us for publication consideration. If we accepted a product, we would provide editorial and production assistance and then market the product. As the company grew, so did our ability to provide a collaborative, internal system of developing products. Today, we internally develop most of our test products in collaboration with outside authors.
Bob Smith: It’s much more expensive now to develop tests than it was in 1977. Unfortunately, the potential revenue doesn’t support the development of some good products today. And because it is so expensive to develop most new tests and because our staff has great test development expertise, we most often develop tests in collaboration with external authors.
Bob Smith: Typically, it takes 3-5 years to develop a test from its conceptual stage to a finished product.
Cathy Smith: We presently have over 40 tests and new software products in development.
Bob Smith: I strongly disagree with the current philosophy that all information on the Internet was intended to be free to share. It costs a significant amount of money to develop a product.
Bob Smith: Thankfully, no. We’re in an industry where the sale of our products is restricted to those who have certain qualifications as well as the training to use our tests. In addition, the tests are supposed to be kept secure. People in our industry understand that a stolen test could completely invalidate its use. So stealing is not nearly as prevalent as it is in other industries, at least not yet.
Cathy Smith: We are very careful about whom we sell our tests to and how our tests are distributed.
Bob Smith: In addition to having the copyright notice on all our tests, we also print a warning on our tests that states that if this test is not printed in a specific color of ink on white paper, then it’s an illegal copy.
Bob Smith: Yes. And we follow up on every one that is reported to us. Sometimes we even have to notify the head of an organization that one of their employees is illegally reproducing our tests.