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Historically, medical settings have provided a fertile environment for formal psychological assessment. Infact, primarily as a consequence of the large number of training opportunities provided by Veteran’s Administration hospitals, a majority of clinical psychologists have had internship and other levels of training within medical settings. Moreover, the specialties of clinical health psychology and clinical neuropsychology had their genesis and seminal growth within medical settings. Within a wide range of medical settings, formal assessment activities by psychologists have become so commonplace as to now be taken for granted by physician colleagues who have trained recently in major urban American medical schools. That is, recently trained physicians now expect to have psychological assessment resources available within the hospital systems in which they practice because these resources were present within the institutions in which they were trained.
In this research paper, we discuss and delineate general and specific issues that currently are important to psychological assessment activities in medical settings. Included in the topics we discuss are unique aspects of the environment and unique assessment issues, assessment with specific medical populations, and opportunities for psychologists practicing assessment in medical settings. Unless otherwise specified, our use of the terms psychological assessment encompass all traditional (e.g., personality, intellectual, academic) and specialized (e.g., healthillness coping styles, specific neuropsychological) testing. We endeavor to be explicit when issues pertain only to a subset of formal psychological assessment procedures.
Unique Generalaspects of the Medical Environment That Affect Psychological Practice
In general, there are a number of characteristics of medical settings that influence—and in some instances even guide— practice activities of psychologists. These characteristics include the organizational structure of some medical settings (e.g., hospitals), the ubiquitous nature of the medical model of conceptualizing and delivering services, the predominant power and authority conferred to the medical degree (MD), the increased pressure for accountability associated with physical health care, opportunities for clinical collaboration with physicians, opportunities for professional learning and growth, possible involvement in medical education, possible involvement in medical research, and multidisciplinary aspects of health care in some medical settings. We consider each of these factors individually.
The decision-making power and authority of hospitals and other medical service delivery institutions is structured—like most large businesses—in a hierarchical administrative tree. Although in the past many of the top leadership positions in hospitals were occupied by physicians, the vast majority are filled currently by individuals who have earned a master’s of business administration (MBA) degree, specializing in hospital administration or health services administration. The chief administrators (e.g., chairman of the board, chief executive officer, chief financial officer, president, vice president) make business decisions, such as those related to marketing, limiting expenses and developing revenues from day-to-day operations, and planning for future growth. As the administrative structure reaches downward to clinical departments and then to clinical programs, the leadership is much more likely to have had training in a health care delivery field (e.g., nursing or medicine) and to be licensed clinicians as well as administrators. The important decisions regarding targeting of health care problems and effective delivery and quality control of relevant services occur at this level. Although a sharing of financial responsibility occurs throughout the administrative structure of hospitals, it is a relatively recent event at most health care institutions that individual health care providers, who occupy the lowest level of the administrative tree and therefore have the least amount of power and authority, are held accountable for a personal budget of expenses and revenue. This latter event has caused a paradigm shift with regard to the clinical expectations and daily activities of practitioners, including psychologists, within large organized medical settings, such as hospitals. Essentially, there is now a clear burden for a practitioner to earn the equivalent of salary and benefits, plus a substantial amount that is typically defined by top administrators, through collection of real dollars in order to justify the practitioner’s clinical position. The influence of this environment extends to psychologists practicing assessment in medical settings.
Power and Authority Conferred to Holders of MD
Although their amount of unquestioned power is decreasing with the passage of time, individuals who have earned an MD continue to be at the top of that part of the administrative tree that governs clinicians providing services within medical settings. For example, in a multidisciplinary rehabilitation program, the top leadership position is almost always an MD. This physician is referred to as a medical director and is conferred a position of decision-making power over other individuals—even fellow physicians and others licensed as independent practitioners who do not require medical supervision. Although some notable exceptions can be identified (i.e., psychologists sometimes serve as clinical directors with a purview over physicians), most psychologists working in medical settings work in some sense under a medical director, who may or may not appreciate the unique aspects of psychological service provision. Moreover, awareness and knowledge of specialty assessment services delivered by psychologists may be limited.
Pressure for Accountability Associated With Physical Health Care
American society has come to believe that when it comes to medical care, a negative outcome—regardless of whether it is associated with quality care—potentially may raise the issue of accountability. With impressive developments in science and technology that have fostered true medical advances has come unyielding optimism that nearly all illnesses can and should be controlled or ameliorated with early diagnosis followed by appropriate, good care. This perspective is an understandable outgrowth of rapid progress in recent decades and represents a human attribute that drives us incessantly toward higher accomplishments. The other side of the coin consists of perfectionistic expectations that errors can be reduced to zero and that effectiveness can be maximized at all times. As health care practitioners who work closely with physicians, psychologists are placed under the same expectations of accountability. One has only to explore litigation against psychologists to understand that although the damages may or may not be as visibleas those resulting from use of a scalpel, accountability for psychological diagnostic and treatment activities is just as real as for more seemingly tangible medical fields, such as dermatology. Within medical settings, accountability for accuracy of providers individually and clinical procedures in general often is readily apparent among health care workers operating in close proximity. This close accountability for efficacious outcomes is applied in the same manner for psychological assessment outcomes of an individual provider and—for better or worse—will be readily apparent to the nonpsychologists working alongside psychologists within a medical setting.
Opportunities for Clinical Collaboration With Physicians
Within medical settings, psychologists can encounter numerous unique opportunities for collaboration with physician colleagues. Physicians are more than just a referral source for patients; psychologists working in medical settings with physicians can encounter opportunities to work more closely together for the purpose of providing a wider range of services or perhaps reaching a more diverse medical population than would otherwise be seen for psychological services. For example, the close monitoring of mental status changes in patients with acute medical conditions—such as those found in patients hospitalized with onset of central nervous system infections or cerebrovascular stroke—makes for a close clinical collaboration that is not present in outpatient private practice settings. These sorts of close clinical relationships have at times led to improved clinical service delivery that would not have occurred otherwise. For example, monitoring via repeat neuropsychological screenings of patients suffering from brain involvement of AIDS during intense inpatient medical treatment often provides earlier indication of treatment effectiveness than would be possible using only traditional medical markers of brain function. Similarly, psychological screening of candidates for surgical procedures ranging from high-risk, resource-draining procedures (e.g., organ transplantation) to common surgeries, the outcomes of which are known to be affected by psychosocial variables, has increased the frequency of positive outcomes. Finally, from a very different perspective, when one considers the medical cost offset literature (cf. Sobel, 2000), which has demonstrated that appropriate psychological assessment and intervention can produce savings on what would have been unnecessary medical assessment and treatment, it is apparent that utilization of psychological assessment services has a meaningful impact in reducing health care costs. Although it is often overlooked, this latter point is perhaps the most unique contribution of psychological services to overall improved health care, an effect produced as a direct by-product of close collaboration between physicians and psychologists.
Multidisciplinary Aspects of Current Health Care in Medical Settings
Perhaps nowhere has there been more opportunity for psychologists than in multidisciplinary clinical programs, which are almost invariably housed within medical settings and staffed partly by physicians. These programs have grown from the recognition that in order to provide the best care for some medical conditions, the special skills of more than one field are needed. For example, a psychologist working within a hospital may have the opportunity to become part of a multidisciplinary inpatient oncology program, thereby assessing and treating patients who are more acutely ill or who have progressed to the point in their illness that outpatient care is no longer feasible. This multidisciplinary type of endeavor may involve physicians from multiple specialties and specialists from other disciplines, such as physical therapy, speech therapy, and nursing. Similar examples of common real-life collaborations between psychologists in medical settings and various health care professionals can be seen with multidisciplinary rehabilitation, cardiac disorders, epilepsy, neurodegenerative disorders (e.g., Parkinson’s disease, Alzheimer’s disease), stroke, traumatic brain injury, chronic pain treatment, dental problems, and organ transplant programs.Within these programs, psychologists often play a key role—in a well-integrated fashion with other specialists—in evaluating and treating psychosocial, cognitive, and family problems associated with the respective medical disorder.
Unique Opportunities for Professional Learning and Growth
Accompanying opportunities for meaningful and close collaborative involvement with physicians are opportunities for professional learning and growth in what would be considered nontraditional areas for psychologists. For example, neuropsychologists may be able to participate in invasive diagnostic procedures, such as the Wada procedure (i.e., assessment of cognitive and motor function during intracarotid sodium amytal injection to each hemisphere of the brain) that take place in surgical rooms. Such multidisciplinary assessment procedures are administered to patients who are under consideration for surgical intervention in areas of the brain where loss of language may occur. These types of sophisticated, highly specialized assessment opportunities only take place in medical settings.
Possible Involvement in Medical Education
Some medical settings—particularly hospitals and medical centers associated with university medical schools—provide psychologists practicing assessment with opportunities to become involved in the educational process of physicians in training. In fact, psychologists have been well represented in physician training programs for many years. More than two decades ago a survey revealed that 98% of all medical schools in the United States employed psychologists, at a ratio of 1 psychologist for every 24 medical students (Gentry & Matarazzo, 1981). The professional identity of psychologists in medical schools crystallized with the formation of the Association of Medical School Professors of Psychology, an organization that subsequently evolved into the Association of Medical School Psychologists. This organization has recently adopted the Journal of Clinical Psychology in Medical Settings as its official publication and achieved the status of an official section within Division 12 (Clinical Psychology) of the American Psychological Association.
In a different vein, involvement in assessment activities within academic medical settings is likely to bring clinical involvement with medical students and residents who are struggling academically. Such involvement may be in the form of assessment of apparent psychological difficulties, possible substance abuse, or possible learning disability.
Possible Involvement in Medical Research
Following from the latter three points elaborated previously, some medical settings and some collaborations between psychologists and physicians offer unique medical research opportunities. For example, a neuropsychologist may contribute to medical research by assessing patients’ psychological and cognitive functioning before and after the implementation of pharmacological or surgical intervention. Specifically, a neuropsychologist may conduct pre- and postoperative evaluations of patients suspected of normal-pressure hydrocephalus. There may also be an opportunity to work with patients to evaluate their neuropsychological status immediately before and after surgical intervention for an intractable movement disorder. In this manner, the assessment instruments of a neuropsychologist may provide the most salient outcome measure for groups of patients assigned to different types of surgical interventions in an attempt to determine the most effective treatment of a medical disorder. In addition, quality-of-life measures from health psychology have also been utilized in medical treatment outcome studies of cancer patients (and other medical patients) in an attempt to objectify the possible psychosocial benefits of medical interventions to prolong life.
Unique Psychologicalassessment Issues Within Medical Settings
Here, we individually consider the following factors that can affect the assessment practices of psychologists in medical settings: reimbursement, ethical-legal, logistics, and special instrumentation. The reader should note that in some instances, these factors create a favorable effect, whereas in other instances they create an untoward effect for clinicians as compared to those not practicing in medical settings.
Although obtaining reimbursement for services legitimately rendered has become more difficult for all health care providers in recent years, there have been particular issues and emphases for those practicing within medical settings. These factors fundamentally all relate to characteristics and expectations of payer sources.
Piotrowski (1999) presented evidence that “. . . managed care policies are having an onerous influence on the majority of practicing clinicians, particularly in the area of assessment” (p. 792). For psychologists practicing assessment in medical settings, managed care has presented a mixed picture of challenges and—in some instances—some advantages. Beginning with the latter, among the advantages of practicing within medical settings may be easier access to managed care panels that are intent on offering a continuum of care that includes outpatient and inpatient services from the entire range of health care disciplines, including psychology. The restriction of access to patients by exclusion of some psychologists from managed care panels has been significant enough to cause the American Psychological Association (APA) to engage in lawsuits against some managed care companies (see Nessman & Herndon, 2000). When psychologists providing clinical services are fully integrated into larger medical practice groups, inclusion in managed care panels may be facilitated. Individual clinicians not associated with large groups of providers of medical care (e.g., hospitals, independent physician associations) within a given economic geography may not appear as attractive to managed care organizations, who may prefer to sign up the entire continuum of care in one major agreement with a well-established medical institution. This appears to have been particularly true in well-populated, urban areas, within which large medical delivery systems already had earned a positive reputation that made for very favorable marketing once signed up by a particular managed care organization.
Moreover, after they are accepted by the managed care company for inclusion on provider panels and therefore accessible to their subscribers, psychologists in large, wellorganized medical settings also benefit from the available infrastructure of their employer’s organization. Pandemic to at least the current iteration of managed care have been a number of burdensome tasks for clinicians. For psychologists practicing in large medical settings, such as hospitals, there is more likely to be a better support system for the incredibly time consuming tasks of (a) completing unrelenting paper work associated with initial applications and maintenance of panel memberships, (b) accurate completion of extensive and obfuscated precertification procedures, and (c) effective submission and resubmission of proper service delivery and billing documentation. Although subsequent collection procedures are by no means more likely to be effective in large medical institutions, and in many may even be far less effective, the employment relationships of many psychologists to their institutions may be less concerned with actual collections than are those in the private sector.
On the negative side of the ledger, psychologists practicing within the organized multidisciplinary practice group of a medical setting may have to accept panel inclusion for managed care plans that provide relatively better medical coverage than do carved-out (i.e., separately administered and often separately owned) behavioral health plans. Providing services to patients with carved out insurance can be problematic, inasmuch as psychologists are more frequently being reimbursed from the behavioral health portion, rather than the medical portion, of health insurance benefits. In fact, particularly discouraging is the fact that carved-out behavioral health plans proactively may discourage thorough and formal psychological assessments, preferring a less expensive, routine diagnostic interview; a few have a blanket prohibition against neuropsychological evaluations, and some do not ever cover testing for learning disabilities.
Within our own large medical group practice, psychologists have at times been forced to provide services to the patients of our own physician practice group, even though doing so under the capitated insurance benefit (i.e., when clinicians assume risk of inadequate monies to cover necessary care for their patients) meant operating at a loss for that subset of patients. Similarly, when the patient’s primary care services have been paid from a different portion of the patient’s health insurance coverage, there have been instances of no reimbursement’s being available for some psychological and neuropsychological assessment services—a situation that can prove very awkward in maintaining a good working relationship with a referral source.
Within each region of the United States, Medicare establishes what it considers to be acceptable (i.e., reimbursable) clinical care and the billing procedures required in order to obtain partial reimbursement of standard charges for clinical services. Although the specifics are well known to vary from region to region (e.g., the maximum number of hours for neuropsychological assessment per patient that can be considered without special documentation), there are some general overarching issues in all Medicare regions. For example, the most important consideration in providing psychological assessments to Medicare patients is the documentation of medical necessity. In most instances, the documentation of medical necessity is provided by the fact that a physician generated the referral. When bills are submitted, the referring physician’s unique physician identifier number (UPIN) is submitted along with patient and provider identification and billing charges.
However, Medicare can deem certain clinical procedures, identified by current procedural terminology (CPT) codes— often linked to certain diagnoses, identified by International Classification of Diseases (ICD) codes—as not medically necessary, even with physician referral. For example, in the Illinois and Wisconsin Medicare region, evaluation with neuropsychological instruments when the diagnosis involves adjustment disorder is considered not medically necessary and therefore not permissible to submit for billing. Despite the fact that the diagnosis cannot be known in advance, providers must take responsibility for understanding the Medicare rules and policies concerning psychological and neuropsychological assessments within their region. Also, such procedures as the Minnesota Multiphasic Personality Inventory–2 (MMPI-2) must be billed using a psychological test procedure code, even if contained within a neuropsychological testing battery, and a Mini Mental Status Examination (MMSE) is considered part of a diagnostic interview and should not be billed with a neuropsychological assessment code.Those who fail to follow such rules run the risk of rejected bills at the minimum and audits and possible legal and financial penalties at the maximum. A second major issue pertaining to Medicare and especially relevant to psychological assessment in medical settings is the incident to provision. Basically, with regard to clinical psychology, this provision requires that when providing psychological assessment or treatment to hospitalized patients, the licensed psychologist whose name appears on the bill must provide all services submitted to Medicare for partial reimbursement. That is, the time and associated charges for assistants who are in the employ of the psychologist and who provide part of the services to a Medicare inpatient will not be reimbursed. This problem can be substantial for busy hospitalbased consultation programs. In fact, survey data indicate that in 1999, 69% of board-certified neuropsychologists in Division 40 (the Division of Clinical Neuropsychology within the American Psychological Association) used assistants in carrying out formal evaluations (Sweet, Moberg, & Suchy, 2000). From a broader and larger sample of the memberships of Division 40 and the National Academy of Neuropsychology (NAN) in 2000, Sweet, Peck,Abramowitz, and Etzweiler (in press) found that 54% of clinical neuropsychologists were using assistants.
The relatively recent education of professionals and aggressive enforcement by Medicare related to incident to services has curtailed and changed some inpatient assessment activities, either through use of different personnel, reducing services, or billing fewer hours. Specifically, the survey data from Division 40 and NAN members found that 85% of inpatient Medicare providers reported administering fewer tests than normal, and of these 45% reported that quality of care with these patients suffered as a result. Moreover, 12% reported that they have stopped seeing Medicare patients as a result of restrictive practices. Medicare’s incident to billing restriction is apparently related to 24% of neuropsychologists reporting that because of the restriction assistants are not used and to another 45% of neuropsychologists not billing for assistant time. This factor as well as the additional limitation of a maximum allowable billing time have likely been causative factors leading 69% of clinicians to report writing off without billing some portion of the actual hours spent providing services to Medicare inpatients.
As noted previously, psychologists working in medical settings such as hospitals and other types of formal health care organizations may be part of large health care provider groups. As such, individual members may be forced to take referrals from a variety of payer sources, including those for whom there is very poor reimbursement for psychological and neuropsychological assessment services as defined by managed care contracts for those for whom there is no reimbursement possible at all. Unlike clinicians in private practice, providers working in institutions are likely to not have the choice of socalled cherry picking (i.e., accepting referrals with ability to pay most or all of billing charges while declining to see patients with little or no insurance coverage). Similarly, a recent national survey of clinical neuropsychologists (e.g., Sweet et al., in press) showed a lower proportion of forensic cases, which are known to pay full fee, and self-pay cases among those providing assessment services in medical institutions compared to private practice. As was discussed previously in the section regarding managed care, loss of freedom to decline patients can be a negative incentive for psychologists who practice as employees or affiliates to provider groups in some medical settings.
Reimbursement Obstacles to Timeliness and Length of Testing
Clinical psychologists engaged in formal testing, especially neuropsychologists, have for some time been struggling with the ability to self-determine when assessments can be delivered and the length of time spent in a single neuropsychological evaluation. In fact, with regard to the latter issue of length of testing, Piotrowski (1999) has opined that what traditionally was considered a “comprehensive test battery” by clinical psychologists will be a “moribund clinical activity, at least where third-party reimbursement and managed care constraints are an issue” (p. 792). The forces against which psychologists have struggled to provide timely assessments that are clinically appropriate in length of spent time with the patient are managed care and Medicare. Both the managed care industry and Medicare have attempted to contain costs of psychological assessment services by limiting the number of hours of testing per evaluation that will be reimbursed. For example, it has become common for a managed care company to approve only a diagnostic interview, which is then followed by a negotiation between the clinician and a managed care representative with regard to which procedures will be reimbursable and how many hours of testing will be reimbursed. This circumstance is common both within and outside of medical settings. What is particularly difficult for those practicing within medical settings is that the immediate management of the very ill medical inpatient (e.g., new stroke patient) or acutely disordered but less ill medical setting outpatient (e.g., Parkinson’s disease or epileptic patient under deteriorating medication control) may or may not allow for the slow and efficient authorization process. Even more problematic in some instances is the real possibility that the managed care company may authorize substantially fewer hours or not authorize any hours of formal testing. Frequently, psychologists feel obligated to provide services that may then be either underreimbursed or not reimbursed at all.
In contrast to managed care, Medicare insurance coverage does not normally delay delivery of services; however, Medicare coverage is limited to a set number of reimbursable hours of testing annually. When more than the allowed number of hours are delivered, reimbursement requires special written documentation of greater-than-normal medical necessity. Because the special authorization must take place at the time of billing (i.e., after the delivery of services), denial of the request results in nonreimbursement, which is essentially an unexpected contribution to free care.
Consultation-Liaison and Emergency Referrals
Some of the formal assessment services provided within medical settings are associated with a degree of timeliness that requires special consideration not normally seen outside of medical settings. Psychologists providing assessment services within medical settings may be asked to interrupt their daily activities to provide very rapid response to an inpatient. For example, a brief baseline neuropsychological screening of a patient scheduled for imminent surgery may be requested, or the abrupt change of mental status in a hospitalized cardiac patient with heretofore normal neurological status may bring in requests for rapid consultations from neurology, psychiatry, and neuropsychology. Such requests are unique to medical settings in their requirements of extremely rapid assessment and feedback to the referral source. There is no time for insurance carriers to authorize services in advance of this type of clinical psychological assessment.
Financial Efficacy of Assessment
As the expenditure of health care monies has come under closer scrutiny, questions regarding containing costs of insurance coverage for psychological assessment have grown to include demonstration of financial efficacy. Responding to this exigent situation, made more so by the fact that little research has gathered data relevant to this issue (Ambrose, 1997), Groth-Marnat (1999) proposed seven rational strategies that can be used to enhance financial efficacy of clinical assessment. Given the increased pressure for rapid services, efficiency of service delivery (often related to needing to see more patients within the same amount of time), and cost containment within institutional medical settings, Groth-Marnat’s recommendations seem particularly well suited to psychological assessment within medical settings. These recommendations were as follows:
- Focus on domains most relevant for treatment planning and outcomes.
- Use formal assessment for risk management.
- Target conditions most likely to result in financial efficacy.
- Use computer-assisted assessment.
- Use time-efficient instruments.
- More closely link assessment, feedback, and intervention.
- Integrate treatment planning, monitoring progress, and evaluating outcome.
With these considerations in mind, Groth-Marnat suggested that research pertaining to financial efficacy of formal psychological assessment include specific impacts on cost benefit (financial gain resulting from an expenditure), cost effectiveness (gains in such areas as quality of life and wellness that cannot easily be expressed in monetary units), cost offset (expenses reduced by utilizing a less expensive procedure in place of one that is more expensive), and cost containment (general efforts to reduce costs through limiting procedures covered or frequency of service utilization). To be clear, the question being addressed to the clinical psychologist practicing in medical settings is not whether there is empirical support for psychological assessment activities in health care settings (see reviews of empirical support by Kubiszyn et al., 2000; Meyer et al., 2001); it is whether these activities can be justified on an economic basis. It is not difficult to imagine that although relevant financial efficacy research data will be very helpful in answering this question at the national level, which can affect managed care policy positively, the most salient information may be that which is gathered at the local level and targeted to specific service delivery systems. In this latter regard, the prominence of the scientist-practitioner approach, a mainstay of individual and programmatic service delivery of clinical psychologists in medical settings (Rozensky, Sweet, & Tovian, 1997; Sweet, Rozensky, & Tovian, 1991), seems ideally suited to the task.
Ethical and Legal Issues
Ability to Give Informed Consent for Assessment
Concerns regarding the need for documenting informed consent for assessment—as has been more common with treatment—have been well articulated and appear cogent (see Johnson-Greene, Hardy-Morais, Adams, Hardy, & Bergloff, 1997, for a discussion pertaining to neuropsychological assessment). Yet, there are unique aspects of medical settings that increase the likelihood that ethical guidelines may conflict with patient-related situations that may be uncommon— or even nonexistent—in other practice settings. First, within medical settings there are more likely to be seriously ill patients whose conditions may impair or at least bring into question their ability to give consent for diagnostic testing and treatment. As the APA has moved toward more explicit guidelines and expectations regarding the need for informed written consent for treatment and assessment, the ethical dilemma for practitioners engaged in assessments with seriously ill patients has increased meaningfully. For example, when a medical inpatient becomes a management problem and also refuses treatment, it is appropriate for physicians to call upon colleagues such as clinical psychologists and neuropsychologists to better determine the problem and related solutions. A medical inpatient who is not able to understand the dire consequences of refusing treatment that would correct the underlying medical situation and also return the patient to competent cognitive status may not have the legal right to refuse the treatment agreed upon by physicians and responsible family members. However, what if the assessment that objectively would document the cognitive incapacity and the need for others to judge the medical necessity of treatment is not possible because the patient also will not cooperate in providing written informed consent? Is a psychologist vulnerable to legal or ethics action if the assessment is carried out without informed consent?
At present, there is no completely satisfying answer for this difficult situation.When informed consent cannot be obtained because the patient is either uncooperative due to delirium or not competent to be truly informed due to dementia, many practitioners rely on the direction and approval of close family members before proceeding. The notion of considering and including family members in a process of medical decision making rests on a philosophical position that views informed consent as a collaborative decision making process in which values and thinking related to informed consent “are not the hidden and privileged property of the individual” (Kuczewski, 1996, p. 35). The direction of decisions derived in such a process is best documented in writing, with an endorsing signature of a family member, if possible. However, it is also noteworthy that inpatient services will at times be requested when it appears that no patient family member is available to sign consent for the evaluation or for the release of information.Undersuchcircumstances,thepsychologistmayhaveno choice but to document in writing that consent could not be obtained, before proceeding. This topic brings us to the next section, which is related.
Competency Issues in Medical Settings
Inpatient medical settings are more likely than any other type of outpatient clinical setting to involve questions pertaining to competency. Competency is a legal concept, not a medical concept, which—in order to be established as present or absent by legal standards—relies upon observations, opinions, and data from health care providers. Melton, Petrila, Poythress, and Slobogin (1997) note multiple delineations of competency pertaining to criminal matters, including competency to consent to search or seizure, competency to confess, competency to plead guilty, competency to waive the right to counsel, competency to refuse an insanity defense, competency to testify, and competency to be sentenced and executed. These authors also note numerous civil competencies, which have more bearing in psychological assessment with medical inpatients. These are competency to make treatment decisions, competency to consent to research, and testamentary competency. Although the latter two types have relevance, competency to make treatment decisions is perhaps the most salient within medical settings (e.g., Feenan, 1996; Pollack & Billick, 1999), and in particular for psychologists performing inpatient psychological assessments. Setting aside the legal discussion of relevant constructs, the sum of which surpasses the space limitations of this research paper, competence to accept or refuse treatment fundamentally requires the following, subsequent to appropriated disclosure regarding treatment:
At a minimum the clinician will want to learn the patient’s understanding of the nature and purpose of the treatment; its risks and benefits; and the nature, risks, and benefits of alternative treatments. Under the “appreciation” and “reasonable process” test of competency, it will also be important to determine the patient’s reasons for consenting or refusing consent. (Melton et al., 1997, p. 355)
The notion of whether a patient is capable of understanding relevant facts and circumstances is part of virtually all types of competency and is the fundamental reason that psychologists are often called upon to provide quantitative evidence of cognitive capacities when issues regarding competency arise. To serve this purpose, psychological test data pertaining to verbal reasoning, learning and memory, and other cognitive domains can be used—in conjunction with information and observations of physicians and others—to assist a judge in establishing the legal presence of competence or incompetence (e.g., Marson, Chatterjee, Ingram, & Harrell, 1996; Marson & Harrell, 1999; Marson, Hawkins, McInturff, & Harrell, 1997). A variety of specific quantified cognitive measures have been constructed for the purpose of addressing issues of competency in medical settings (e.g., Billick, Bella, & Burgert, 1997; Etchells et al., 1999; Glass, 1997; Grisso, Appelbaum, & Hill-Fotouhi, 1997; Holzer, Gansler, Moczynski, & Folstein, 1997; Marson, McInturff, Hawkins, Bartolucci, & Harrell, 1997).
Whereas it has been advocated that children and adolescents—within the limits of cognitive and social development—be involved in medical decision making (McCabe, 1996), minors may not have an absolute right to consent to or refuse medical treatment (cf. Williams, Harris, Thompson, & Brayshaw, 1997). That is, although it may be best from a psychological standpoint to involve children and adolescents in decision making regarding their own medical care, legal standards ultimately bestow final authority to parents or legal guardians.
From both legal and medical perspectives, lack of competence to undergo informed consent and make decisions with regard to treatment has implications for helping patients make decisions regarding advanced directives, such as health care power of attorney and a living will (Ahmed, 1998; Chen & Grossberg, 1997). These decisions require adequate cognitive capacity. For that reason, patients with medical conditions in which illness progression is likely to lead to cognitive incapacity should be educated early regarding the importance of completing advance directives and taking care of personal financial matters (including a legal will that requires that legal standards of testamentary competence be met) while it is still possible to do so.
Unique Quality-of-Life Versus Death Issues
With the advent of sophisticated medical technology that can prolong life, occasionally at the cost of quality of life, some seriously ill patients within medical settings may confront physicians, psychologists, and other health care professionals with very complex decisions. With examples such as choosing to forego kidney disease for renal disease (Tobe & Senn, 1996) and determining a consensual threshold beyond which slowing the progression of Alzheimer’s disease may not serve the patient (Post, 1997) and hastened death requests associated with terminal illness (Farberman, 1997; Hendin, 1999), it seems the choice to discontinue lifeprolonging treatment becomes an issue worthy of consideration. Psychologists working in certain specialty programs, especially as technology to keep very ill patients alive continues to improve, can expect to be involved with other health care professionals in attempting to establish the presence or absence of certain factors (e.g., treatable depression, serious cognitive compromise) in an individual case. In part, the contribution of the psychologist in assisting with this differential diagnosis may come from formal psychological assessment. For example, Smithline, Mader, and Crenshaw (1999) demonstrated that on the basis of formal intellectual testing, as many as 20–32% patients with acute myocardial infarction probably had insufficient capacity to give informed consent to participate in emergency medicine research. Without formal psychological testing, only 8% of these patients were suspected of having insufficient capacity for informed consent.
Limits of Confidentiality
Medical settings may present rather unique concerns regarding confidentiality. Whether inpatient or outpatient, numerous medical settings involve multiple clinicians and sometimes multiple disciplines. Patients and other health care professionals outside of psychology may or may not understand the realities of confidentiality with regard to such settings. For example, multidisciplinary outpatient clinics and inpatient medical settings often maintain, at the specific direction of the Joint Commission on Accreditation of Healthcare Organizations (JCAHO), a single centralized chart, wherein all medical, nursing, and mental health records are stored. For psychologists providing formal assessment services within such settings, there may be a pressure to store psychological test results in this single patient chart, even though state law and professional guidelines and ethics standards may require storage in a separate chart. In order to maintain adequate test security of the test forms, questions, and answers, as well as to protect unnecessary disclosure by another party (e.g., medical records department staff) of detailed personal and psychological information, a separate psychological testing record should be maintained. In order to accomplish this task, clinic, hospital, and office support staffs need to be educated about the special circumstances pertaining to storage and maintenance of psychological test records. When applicable (e.g., when a formal psychological test report is to be placed in a common inpatient hospital chart), patients should be informed of the degree to which psychological test information may be accessed by others. Alternatively, policies can be adopted proactively by the psychologist to safeguard against unimpeded access; for example, psychological test reports can be provided only to the referral source rather than placed in a common file.
Some unique ethical and legal issues associated with medical settings relate to the dying patient. In the course of an assessment of an inpatient whose terminal condition has just been discovered, a psychologist might be asked by the patient for information that has not yet been shared with the patient by the rest of the health care team. Or the dying patient may divulge important and previously unknown psychological information that would be destructive to the rest of the family if that information were shared and divulged by the health care team, who in turn may not understand the patient’s reactions without being informed of the provocative information. Alternatively, what should a psychologist do if while evaluating a dying patient, the patient confesses to serious illegal activities that, if he or she survived, would almost certainly be prosecuted?
Limits of Recommendations for Medical Patients
Medical patients have a variety of assessment and treatment needs, some of which are addressed by psychologists and others of which are either (a) outside the scope of psychological practice or (b) not part of the services requested by the physician referral source. The first category may appear at first glance to be clear-cut in that psychologists do not practice outside the scope of their training and the limits of licensure. However, there can be a conflict stimulated by referral questions raised by the referral source that may, for an individual psychologist, not be within his or her expertise (e.g., frequent questions from physicians regarding the psychologist’s suggested choice of particular medication after an assessment-based recommendation for an antidepressant medication evaluation has been made). Whether the psychologist has considerable relevant expertise pertaining to such a scenario determines the limits of responses that can be made, all of which must be within current licensing limits.
Response to the second category can be even thornier. For example, if an assessment pertaining only to impaired memory uncovers suicidal ideation and a suicidal plan, presumably no one would suggest that the psychologist should not recommend appropriate treatment, regardless of the specialty or original referral interests of the referring physician. However, in less emergent circumstances, when asked to assess a particular facet of an individual (e.g., psychological readiness for surgery intended to relieve chronic back pain), if there are additional unrelated needs that are identified (e.g., a long-standing learning disability that obstructs a lifelong dream of obtaining a college degree), should treatment recommendations related to the latter issue be included, even if they are not relevant to the reason for the consultation and not within the purview of the referral source? To elaborate further, psychological assessment services are often delivered within medical settings when the psychologist is in the role of a consultant to another health care professional, most often a physician. In such a situation, the purview and associated latitude of recommendations appear more limited than they would be if the psychologist were being consulted directly by a patient who held the expectation that the psychologist would be in the role of primary responsibility for the broad range of caring for the patient’s psychological needs.
Medical settings, especially hospitals, have some unique characteristics that affect the provision of care, including psychological and neuropsychological assessments. First and perhaps foremost is that the provision of care within hospitals and some other medical settings requires credentialing and privileging of the provider—that is, each provider must have his or her professional credentials (e.g., degree programs, formal nondegree coursework, certifications of training or competence, etc.) placed under peer review that allows a determination of which privileges (e.g., professional procedures associated with the individual’s field of study and practice, such as personality testing or neuropsychological testing) the person will be allowed to perform while working within a given facility. In other words, a psychologist may not simply enter and provide services in a medical facility merely because someone has referred a patient. In most instances, credentialing and privileging at a medical facility implies that the provider will provide services intermittently or with some regularity. However, when a one-time evaluation is requested, temporary privileges can usually be granted expeditiously. These requirements are an expectation of agencies such as the JCAHO. Therefore, it is important to note that merely being hired as an employee of a medical facility is not enough to begin practicing within the facility; credentialing and privileging must still take place, even for a full-time employee of the institution. The facility must still document that an adequate review of credentials and an appropriate granting of privileges for the practice of psychology have taken place. As more psychologists have been hired within medical facilities, more sophisticated and specific credentialing and privileging procedures have been created and entrusted to psychologists rather than medical staff. Thus, currently this intended peer review process is more likely to be a review by one’s true peers (other practicing psychologists) than it has been in the past.
Second, the amount of time within which a psychologist provides assessment services to patients is quite different on an inpatient unit than it is in outpatient practice. In fact, there are three separate time intervals that are considered critical to the provision of responsive inpatient services: (a) starting with the referral being received, time to begin the evaluation; (b) time to complete the evaluation; and (c) time to provide feedback (usually in the form of a written report) regarding the evaluation findings. Currently, as a result of shortened hospital stays, the total time available for all three phases of completing a psychological or neuropsychological evaluation of an inpatient is frequently less than 3 days. Barring difficulties that cannot be controlled, such as patient unavailability and patient lack of cooperation, it is not uncommon in our own hospital system to complete all three phases within 2 days.
A very different and unique logistical problem associated with assessment of inpatients is what Medicare terms incident to restrictions. Essentially, as discussed previously, psychologists must personally provide all the services for Medicare inpatients that are billed. The time spent by paid testing technicians and other assistants in providing psychological or neuropsychological assessment services is deemed not reimbursable by Medicare.Thus, psychologists and neuropsychologists who are hospital-based—and therefore likely to receive numerous inpatient referrals and to use testing assistants— must either organize their practice time differently to provide all services themselves or must write off time spent delivering inpatient assessment services by paid assistants. Although applicable to all psychologists and neuropsychologists— whether in private practice or working within organized medical systems—this policy is particularly difficult for those whose practices are located within hospitals.
Special Instruments and Issues
Assessments in some medical settings require particular attention to the possibilities that (a) the patient may have limited ability to respond, (b) the patient may be seriously ill and possibly infectious, and (c) the nature of the case may require unusual or special testing procedures, equipment, or both. These types of issues are usually not found outside of medical settings. The presence of such issues requires that the psychologist performing assessments (a) maintain a wide array of testing options in order to be able to assess even the most frail medically ill patients at bedside in their hospital rooms; (b) be aware of universal precautions (generally accepted practices for preventing the spread of infection within hospitals) and the possible need to disinfect or dispose of test materials if they become contaminated; and (c) be able to foresee and employ assessment techniques for patients who may be recently or chronically physically, sensorily, or cognitively handicapped. Given the greater acuity of illness currently required to satisfy admission requirements to inpatient hospital programs and the shorter length of hospital stays, decreasing numbers of these patients are suitable for traditional standardized testing instruments.
Assessment Within a Biopsychosocial Model
In medicine, the goals of clinical diagnosis are to identify the ongoing disease process and to formulate a plan to deal with the disease. When psychosocial factors are added to the medicalsymptomatology,thepatientcannotbeseenasasingleentity that carries a group of predictable or constant symptoms requiring evaluation. Rather, psychosocial factors interact with the patient’s premorbid personality to create a changing pattern. Under these circumstances, clinical analysis must not only systematically evaluate these varied elements, but also clarify their interrelationships and changes over time. Current behaviors and attitudes are assessed in conjunction with the physical basis of the presenting problem. Premorbid background is delineated in an effort to clarify the person’s baseline and the historical context for the medical condition. Moreover, using the biopsychosocial model (Belar & Deardorff, 1995; Engel, 1977; Nicassio & Smith, 1995) clinical health psychology has been able to move from an ineffectual model supporting mind-body duality to a model that considers influences of culture, environment, behavior, and beliefs on physiology and symptomatology. This model is not an endpoint in understanding medical patients, but it can serve as an organizing schema for identifying diagnostic questions. Within this approach an attempt is made to assess the interaction of the type of data collected (affective, behavioral, cognitive, or physiological information) with the source from which the data can be collected (the patient, his or her environment, or both).
The goal of a psychologist performing assessments in medical settings is to contribute to a broader understanding of the patient. This information can include an understanding of the patient within his or her physical and social environment; the patient’s relative psychological assets and weaknesses; evidence of psychopathology contributing to, in reaction to, or separate from the physical disease process; the patient’s response or predicted response to both illness and the medical or surgical treatment regimen; and identification of the coping skills being used by the patient and family (Belar & Deardorff, 1995). In addition, the psychologist can be especially helpful to the health care team, the patient, and the patient’s family in assessing the complicated questions surrounding issues of malingering, factious disorders, the interaction of psychological disorders and medical disorders, or the problems of the “worried well” seen in the medical setting (Rozensky et al., 1997).
Assessment information comes from a variety of sources. These sources include interviews, questionnaires and inventories (self-reporting), self-monitoring, direct observation of behavior, and psychophysiological measurement. Each measurement modality must be evaluated uniquely to determine which is the most effective method to use in achieving a valid assessment.
The interview provides the foundation of the assessment process. Interviewing the medical patient requires the basic skills needed in evaluating patients in any setting. Basic to all effective interviewing, the clinician must be able to empathize and develop rapport, gather relevant information to the referral question, make adjustments as a function of process issues and patient characteristics, understand the importance of timing in the disease process and medical treatment intervention, and utilize a theoretical framework to guide the assessment process. More information on the interview process and other modalities in assessment with medical patients can be found in Pinkerton, Hughes, and Wenrich (1982); Hersen and Turner (1994); and Van Egren and Striepe (1998).
Self-report measures are advantageous when external observers cannot achieve sufficient access to that which is being measured (e.g., affect or attitude), cost is crucial, staff time is at a premium, or trained clinicians are not available. Clinical observer rating scales and interviews are usually preferred in situations in which clinical judgment is essential (e.g., diagnosis), the disease process or disability has robbed the patient of the ability to report accurately (e.g., delirium or dementia), or sophisticated clinical decisions are required (e.g., neuropsychological testing). Clinical experience has demonstrated that certain constructs (e.g., quality of life) are best measured via self-report; other measurement tasks have been determined to often require judgment from clinical observers (e.g., diagnostic assessment from the Diagnostic and Statistical Manual of Mental Disorders–Fourth Edition; American Psychiatric Association, 1994). Other aspects of psychological assessment (e.g., psychological distress) may be approached through either modality (Derogatis, Fleming, Sudler, & DellaPietra, 1995).
Another important general issue involves the specific point in time that an assessment occurs. The natural history of many medical conditions may include specific events that place stress on patients’coping abilities. Medical interventions also have noxious side effects that cause psychological effects. Baseline assessment prior to the introduction of any significant treatment intervention would be useful. In addition, it would be ideal if psychological assessments could coincide with major medical diagnostic evaluations and interventions so that information on a patient’s psychological state could be integrated with the overall clinical picture and treatment plan. Finally, with many chronic illnesses, perhaps a comprehensive yearly psychological assessment focussing on quality of life, coping efficacy, and possible psychological distress completed during scheduled medical visits could yield crucial information as the illness, the treatments, or both change over time.
Crucial to effective psychological assessment of medically ill patients is the selection of the most appropriate normative standards or norms to use as referents (e.g., general population norms or illness-specific population norms) when using self-report inventories. The identification of appropriate norms is based upon the nature of the comparison that the psychologist wishes to make and the specific question that is addressed. If the basic question is whether the patient’s psychological distress has reached clinical proportions, then the general population norm may be used because it is much more likely to have well-established so-called caseness criteria associated with it. Comparison with a general norm addresses the question Does this patient have a psychological problem of sufficient clinical magnitude to require a therapeutic intervention? Alternatively, if the referral question concerns the quality of a patient’s adjustment to the illness at a particular stage in comparison with the typical patient, then an illness-specific norm is indicated (Derogatis et al., 1995). Therefore, referral questions involving psychological distress and psychiatric disorder are often sufficiently salient to generalize across groups of patients. Adjustment to a particular illness is a construct that is much more illness-specific and may require the psychologist to interpret adjustment profiles in terms of specific illness stages.
Some variables, such as quality of life, are best assessed in a manner that combines normative data from both general and illness-specific populations. Quality-of-life measures often generate a very broad-spectrum continuum—from a status reflecting optimum health, social functioning, and so forth, to one of indicating serious deterioration of well-being at the other end. In addition, specific medical disorders often involve specific symptoms, problems, and disabilities that require detailed assessment. Investigators assessing quality of life (Derogatis et al., 1995; Mayou, 1990) often use a modular strategy combining both norms. In this paradigm, the illness-specific module may be treated as an additional domain of the general inventory instrument or as a distinct, individual measure.
In their review of psychological assessment, Derogatis et al. (1995) identified five constructs or attributes to measure in patients with medical disease: (a) well-being or affect balance, (b) psychological distress, (c) cognitive functioning, (d) psychosocial adjustment to illness, and (e) personality or health-related constructs. To this end, the authors recommend several screening instruments to delineate whether the patient has a psychological disorder requiring treatment or influencing medical treatment. Screening instruments are not diagnostic tests per se; rather, they represent an attempt to describe whether the patient has a high probability of having a certain condition in question (positive) or a low probability of the condition (negative). Those with positive screening can be further evaluated. The screening instrument should both be reliable (i.e., consistent in its performance from one administration to the next—sensitivity) and have predictive validity (i.e., capable of identifying those with the disorder and eliminating those who do not).
Several examples of psychological and cognitive screening measures and a neuropsychological battery are presented in Tables 13.1, 13.2, and 13.3. The examples presented are not intended to be exhaustive. Instead, they represent some of the most popular and frequently cited in literature reviews on assessment in medical settings (Demakis, Mercury, & Sweet, 2000; Keefe & Blumenthal, 1982; Rozensky et al., 1997; Sweet et al., 1991). For more information on most of these measures, the reader is advised to consult Maruish (2000) and Derogatis et al. (1995). With regard to Table 13.2, Sweet et al. (1997) recommended that neuropsychological screening batteries be used with cases involving differential psychiatric versus neurological diagnosis, including patients with subtle to mild dementia, who require more extensive diagnostic information and more complex case management.These authors recommend that more comprehensive neuropsychological batteries be used with (a) rehabilitation cases, such as stroke and head injury; (b) neurological cases that may involve progression of a brain disorder across time, such as early cases of multiple sclerosis, systemic lupus erythematosus, or acquired immune deficiency syndrome, and those that require baseline and interval testing in which a relatively diverse and unpredictable set of deficits is possible, as in cerebrovascular disease; and (c) presurgical multidisciplinary evaluation of epilepsy cases. Forensic neuropsychological cases also require a comprehensive battery (cf. Sweet, 1999).
Types of Referrals
The nature of a referral question depends upon the psychologist’s role in the specific medical program or setting (e.g.,consultant or full service) and the referral source. Belar and Geisser (1995) outlined three broad areas of assessment: differential diagnosis, provision of treatment, and treatment planning. Differential diagnosis involves assessment of significant psychological contributions to illness. Assessment of the need for treatment can include assessment of patient readiness to undergo a procedure, need for treatment for a particular problem, reevaluation for readiness for the procedure after treatment is completed, and need for concurrent treatment to facilitate a favorable outcome. An example of such a referral would involve whether a patient is a good candidate for cardiac transplant despite being a smoker. In this instance, evaluation, recommendation of smoking cessation intervention, and reevaluation after a period of smoking abstinence may be appropriate.
A final referral area involves assessment that provides an understanding of the commitments of a chronic disease, the sequelae of a particular event, or reaction to illness, so as to facilitate either medical or psychological treatment planning. Examples include identifying problems of adherence to diabetic regimens, assessing individual and family coping strategies in a depressed cancer patient, and delineating cognitive deficits in a brain tumor patient to help in planning for appropriate support services.
Wellisch and Cohen (1985) outline guidelines to be used with medical staff for making assessment referrals. Referral sources are encouraged to refer when emotional or behavioral responses (a) interfere with the ability to seek appropriate treatment or to cooperate with necessary medical procedures, (b) cause greater distress than does the disease itself or increase disease-related impairment, (c) interfere with activities of daily living, (d) result in curtailing of usual sources of gratification or result in disorganization so severe and inappropriate that it results in misinterpretation and distortion of events. Referrals of medical patients are also encouraged when psychological dysfunction is significant from the patient history (e.g., history of suicide attempt, substance abuse).
Positive psychological outcome of surgery is directly correlated with patients’ ability to understand the proposed procedure, recognize its necessity, and tolerate the stress and discomfort associated with the procedure. Several problems, however, can require psychological evaluation and can serve as reasons for referral: a dysfunctional relationship with the surgeon or staff secondary to personality disorder, inability to understand and give consent, severe panic and refusal of surgery, and exacerbation of a preexisting psychiatric problem (e.g., depression, suicide risk).
There are two primary groups of determinants in the psychological adaptation of a patient to surgery. The first group consists of such variables as the patient’s specific combination of salient medical variables (i.e., surgery site, reason for surgery), functional deficits resulting from surgery, rehabilitation potential, and the surgeon’s psychological management of the patient. The second group consists of patient-related variables, such as the meaning that the patient attaches to the need for surgery and the site of the surgery, perception of the surgical consequences, psychological ability of the patient to tolerate a stressful event, and the relationship between patient and surgeon (Jacobsen & Holland, 1989).
Some degree of presurgery apprehension is normal. Patients with traumatic pasts (e.g., sexual or physical abuse) or premorbid psychiatric disorders can be among the most vulnerable to an abnormal level of fear. In addition to fear, patients can feel hopeless, angry, helpless, and depressed. In assessing the presurgery patient, the psychologist needs to consider salient factors associated with a particular site (e.g., mastectomy, which often involves cancer, altered body image, fear of loss of sexual attractiveness; cardiac surgery, with possible altered lifestyle postsurgery and the fact that the heart is viewed as synonymous with life).
Salient interview issues for the presurgery patient involve identifying the exact nature of the symptoms experienced (e.g., cognitive, affective, and somatic components). Interview questions should differentiate several possible characteristics: avoidance often seen in phobias; flashbacks of previous medical, physical, or sexual trauma, all characteristic of a posttraumatic stress disorder (PTSD); nervousness and anxiety for 6 months or more, often seen in generalized anxiety disorders; attacks of panic, fear, and dread for no apparent reason, characteristic of panic disorders; and a maladaptive response to a severe stressor, often seen in adjustment disorders. The interview can also highlight past compliance (or lack thereof) with medical personnel and medical regimen, the patient’s perception of situational demands from surgery and sense of personal control, meanings attributed to the procedure and organ site, knowledge of pre- and postoperative procedures, and desire to obtain information about the procedure.
In addition to measures used to assess brief cognitive functioning, psychopathology, and affect, it may be useful to consider questionnaires pertaining to coping (e.g., Ways of Coping; Folkman & Lazarus, 1980) and locus of control (e.g., Multidimensional Health Locus of Control; Wallston, Wallston, & DeVellis, 1978) in presurgery assessment.
A spectrum of postoperative central nervous system dysfunctions, both acute and persistent, has been documented after cardiac surgical procedures, including stroke, subtle neurological signs, and overt neuropsychological impairment (Newman et al., 2001). In fact, Murkin, Newman, Stump, and Blumenthal (1995) summarized a group consensus statement from experts, highlighting the need for a standardized core battery of neuropsychological tests to be employed with cardiac surgery patients. The group consensus also indicated that mood state assessment should be evaluated concurrently because neuropsychological performance can be influenced by mood state. Although it is arguable whether the panel in its specific test recommendations achieved its stated purposes (i.e., identifying specific tests relevant to the postsurgical phenomenon documented in the literature that would minimize practice effects due to necessary repeat testings), the goals were sound. Although supplementary tests could be added as deemed appropriate, it was envisioned that a core battery could provide a basis for rational comparison across clinical outcome studies and eventually allow combination of study results by meta-analysis. The need for a core battery can also be relevant to other chronic illnesses such as diabetes, in which cognitive and affect changes occur over time (Strachan, Frier, & Deary, 1997).
Organ Transplant Surgery
It is beyond the scope of this research paper to present a detailed discussion of the medical and psychological conditions of potential transplant patients. It is important to note, however, that consideration of organ transplantation is often precipitated by a major medical crisis with a chronic medical condition, and the possibility of death during and shortly after transplantation remains salient. Recent advances in bone marrow, renal, hepatic (liver), and cardiac transplantation have made organ transplantation a viable medical practice.
Organ transplantation remains extremely stressful for patients and their families and involves the allocation of scarce resources (Zipel et al., 1998). Noncompliant patient behavior following transplant surgery can endanger a graft and result in death. Serious psychopathology, including schizophrenia, major affective disorders, and certain personality disorders may interfere with optimal self-care. Toward this end, psychological assessment goals with transplant patients may include (a) determining contraindications to transplant, (b) establishing baselines of affect and cognitive and coping skills for future reference or comparison, (c) identifying psychosocial problems and beginning preoperative intervention, and (d) establishing patient ability to understand the realities of program involvement and postsurgical rehabilitation (Olbrisch, Levenson, & Hamer, 1989).
Rozensky et al. (1997) have outlined a protocol for the assessment of transplant patients as well as psychological contraindications for transplantations.The interview can focus on issues involving knowledge of the transplantation experience and procedures, desire for and reservations about transplantation, adherence and compliance with medical regimen, premorbid health habits (e.g., weight control, exercise, substance abuse), and family reactions. In addition, the Psychological Adjustment to Illness Scale–Self-Report (PAIS-SR), with scoring norms using coronary heart disease patients and dialysis patients, can be helpful in assessing current adjustment to illness and predicting posttransplant patient compliance.
Several authors have assessed psychopathology in both preand postcardiac transplantation using diagnostic interviews with DSM-III formats (Kay & Bienenfeld, 1991; Kuhn et al., 1990; Olbrisch & Levenson, 1991). From these data it appears that approximately 75% of candidates are accepted for cardiac transplant with no significant psychosocial contraindications, approximately 20% of candidates are accepted with preconditions (i.e., specific criteria to be met prior to acceptance, such as completion of weight loss or smoking cessation programs), and 5% are refused on psychosocial grounds. Olbrisch et al. (1989) summarize the ethical problems in the application of psychosocial criteria to transplant assessment—namely, allocating scarce organs and expensive care and technology to those patients likely to derive maximum benefit and longevity. The authors note ethical problems can involve confusing psychosocial factors predictive of survival with judgments of an individual’s social worth (not regarded by most as acceptable grounds for choosing candidates), unjust decisions resulting from inconsistencies in the application of psychosocial criteria across transplantation centers, and use of criteria that are of questionable reliability and validity.
Olbrisch et al. (1989) have developed the Psychosocial Assessment of Candidates for Transplantation (PACT) rating scale to objectify and allow scientific study of clinical decisionmaking criteria in psychosocial assessment of transplantation candidates. Normed on 47 cardiac and liver transplant patients, the PACT was shown to have high interrater reliability, with 96% overall agreement between raters on whether to perform a transplant on a given patient. Less than 5% of all pairs of ratings disagreed by more than one category. The scale shows promise for studying the pretransplant psychosocial evaluation in process and can aid in learning how different programs weight various factors in selecting patients and how these decisions predict clinical outcome. Sears, Rodrigue, Sirois, Urizar, and Perri (1999) have attempted to extend psychometric norms for precardiac transplant evaluations using several cognitive measures, affective functioning and adjustment measures, coping strategies, and quality-of-life measures.
Recent studies evaluated the quality of life in heart and lung transplant recipients before and after surgery (Cohen, Littlefied, Kelly, Maurer, & Abbey, 1998; Deshields, Mannen, Tait, & Bajaj, 1997). The authors in both studies found correlations between extreme pretransplant anxiety levels and poorer posttransplant quality of life. Stilley, Miller, Gayowski, and Marino (1999) found in a study of 73 candidates for liver transplant that past history of substance abuse correlated with more distress and less adaptable coping styles after transplantation.
Patients with psychiatric conditions will be seen by psychologists in medical settings when they develop medical symptoms or because psychiatric treatment facilities exist within or adjacent to medical treatment facilities. In 1991, prevalence rates in the general population for any psychiatric disorder, any substance abuse-dependence disorder, and both mental health and substance abuse disorder were estimated to be 22.9%, 11.3%, and 4.7%, respectively. Prevalence rates for any anxiety disorder and any affective disorder for the same year were estimated to be 17% and 11%, respectively. Lifetime prevalence rates for these conditions were estimated to be 25% and 19%, respectively (Maruish, 2000). As summarized by Maruish, there are significant comorbidity rates of depression with cancer (18–39%), myocardial infarction (15–19%), rheumatoid arthritis (13%), Parkinson’s disease (10–37%), stroke (22–50%), and diabetes(5–11%). The author also summarizes studies that indicate between 50 and 70% of visits to primary care physicians have a psychosocial basis. These figures highlight the need for psychological assessment and screening of psychiatric disorders in medical settings.
Toward this end, the most frequently used instruments for screening and treatment planning, monitoring, and outcome assessment are measures of psychopathological symptomatology. These instruments were developed to assess behavioral health problems that typically prompt people to seek treatment. Frequently used psychopathology instruments are summarized in Table 13.1 and are reviewed in more detail by Rozensky et al. (1997); Sweet and Westergaard (1997); and Maruish (2000).
There are several types of these measures of psychological-psychiatric symptoms. The first category is comprised of comprehensive multidimensional measures. These instruments are typically lengthy, multiscale, standardized instruments that measure and provide a graphic profile of the patient on several psychopathological symptom domains (e.g., anxiety, depression) or disorders (schizophrenia, antisocial personality disorder). Summary indexes provide a global picture of the individual with regard to his or her psychological status or level of distress. Probably the most widely used and recognized example of these multidimensional measures is the restandardized version of the MMPI-2 (Butcher, Dahlstrom, Graham, Tellegen, & Kaemmer, 1989).
Multidimensional instruments can serve a variety of purposes that facilitate therapeutic interventions in medical and behavioral health care settings. They may be used on initial patient contact to screen for the need for service and simultaneously offer information that is useful for treatment planning. These instruments might also be useful in identifying specific problems that may be unrelated to the patient’s chief complaints (e.g., poor interpersonal relations). In addition, they generally can be administered numerous times during the course of treatment to monitor the patient’s progress toward achieving established goals and to assist in determining what adjustments (if any) are needed to the intervention. In addition, pre- and posttreatment use of such instruments can provide individual treatment outcome data.
In a second category, abbreviated multidimensional measures are similar to the MMPI-2 and other comprehensive multidimensional measures in many respects. First, they contain multiple scales for measuring a variety of symptoms and disorders. They may also allow for the derivation of an index that can indicate the patient’s general level of psychopathology or distress. In addition, they may be used for screening, treatment planning and monitoring, and outcome assessment, just like the more comprehensive instruments. These instruments, however, differ by their shorter length and ease by which they are administered and scored. Their brevity does not allow for an in-depth assessment, but this is not the purpose for which they were designed. Probably the most widely used of these brief instruments are Derogatis’s family of symptom checklists. These include the Symptom Checklist-90-Revised (SCL-90-R) and the Brief Screening Inventory (BSI; Derogatis et al., 1995; Derogatis & Spencer, 1982).
The major advantage of the abbreviated multiscale instruments is the ability to survey—quickly and broadly— psychological symptom domains and disorders.Their value is evident in settings in which time and costs available for assessment are limited.These instruments provide a lot of information quickly and are much more likely to be completed by patients than are their lengthier counterparts; this is important if one is monitoring treatment or assessing outcomes, which requires at least two or more assessments to obtain the necessary information. Ironically, disadvantages of these instruments also relate primarily to decreased items: potential absence of or reduced effectiveness of validity scale items, decreased reliability, and (as noted earlier) restricted range of clinical content.
A third category consists of disorder-specific measures, which are designed to measure one specific disorder or family of disorders (e.g., anxiety, depression, suicidality, substance abuse). These instruments are usually brief, requiring 5–10 minutes to complete. They have been thoroughly reviewed by Maruish (2000) in chapters 12 through 17.
Neuropsychological tests are designed to provide information related to the presence and degree of cognitive impairment resulting from brain disease, disorder, or trauma; in some instances, they also can provide information pertaining to diagnosis and etiology. The results of these tests also are used, for example, to draw inferences about the extent to which an impairment interferes with the patient’s daily functioning, ability to return to work, and competency to consent to treatment. There are numerous psychometrically sound neuropsychological measures. Some instruments assess only specific areas of functioning (e.g., immediate visual memory). Others assess broader areas of functioning (e.g., a battery of memory measures that assesses immediate, intermediate, and longterm verbal and nonverbal memory). Still others are part of a battery of measures that aim to provide a more comprehensive assessment of neuropsychological functioning (e.g., a battery that include tests of memory, language, academic skills, abstract thinking, nonverbal auditory perception, sensorimotor skills, etc.). Examples of neuropsychological screening measures as well as examples of comprehensive batteries can be found in Table 13.2.
The top two referral sources for neuropsychologists are psychiatrists and neurologists (Sweet et al., 2000). The typical referral question stemming from a psychiatric setting concerns discriminating between an emotionally based (or psychological) and abrain-based (or neurological) disorder. It is important to avoid the inaccurate and out-of-date conceptualization of functional versus organic as well as either-or dichotomous questions—that is, neurologically disordered individuals can also be psychologically disordered (e.g., depressed), and individuals with significant psychiatric disorders can develop neurological disorders.
Neurology patients are referred for assessment for a variety of reasons, including to (a) establish functioning before and after surgery or other medical intervention, (b) track recovery or deterioration of a known neurological disorder, (c) assist in differentiating psychiatric and neurological disorder, (d) assist in assigning relative contributions of multiple known disorders to clinical presentation, and (e) assist in identifying difficult diagnostic conditions for which there is little or no abnormality on neurological examination or medical diagnostic procedures. Patients with a wide range of neurological disorders are referred for neuropsychological evaluation, including traumatic brain injury, cortical degenerative diseases (e.g., Alzheimer’s disease), subcortical degenerative diseases (e.g., Parkinson’s disease), demyelinating disease (e.g., multiple sclerosis), cerebrovascular disease (hemorrhagic and thromboembolic stroke), primary and secondary brain tumors, seizure disorders, and brain infections (e.g., herpes simplex encephalitis).
Neuropsychological assessment referrals of patients in outpatient or inpatient rehabilitation typically are motivated by the need of the multidisciplinary rehabilitation team to understand each patient’s emotional status and capacity. The two most common acute neurological conditions that lead to subsequent rehabilitation during which they may be referred for neuropsychological evaluation are cerebrovascular stroke and traumatic brain injury. Further discussion of the nature of referral questions from psychiatry, neurology, and rehabilitating medicine with neuropsychological assessment may be found in Rozensky et al. (1997). Demakis et al. (2000) review neuropsychological screening measures and referral issues in general medicine and primary care.
When patients are referred because one or more careful medical workups identify no clear physical findings, their physicians may proceed by diagnosis by exclusion. Because no somatic cause is found, it is hoped that psychological assessment will identify psychosocial or psychological factors that could be causing or maintaining the somatic symptoms.There is a tendency for somatic patients to be referred for psychological evaluation as a last resort. Rozensky et al. (1997) outline approaches to inform referral sources in making a referral for psychological evaluation as well as introducing the assessment to the somatoform patient to avoid increased resistance. The authors also support a comprehensive evaluation utilizing specific interview questions, self-monitoring by the patient, and several questionnaires found in Table 13.1.
Swartz, Hughes, and George (1986) provide a brief screening index to identify patients with probable somatoform disorders. The index can be used in an interview format or by review of patient records. The patient’s physical complaints are categorized according to 11 symptoms: abdominal pain, abdominal gas, diarrhea, nausea, vomiting, dizziness, fainting, weakness, feeling sickly, pain in extremities, and chest pain. To confirm a probable somatoform diagnosis, the patient must have at least 5 of the 11 symptoms without demonstrable medical findings.
Katon et al. (1990), focusing on the prognostic value of somatic symptoms, used the SCL-90-R to provide an operational definition of high distressed—high utilizers. The investigators observed linear increases in SCL-90-R dimension scores of Somatization, Depression, and Anxiety as they moved progressively through the somatic symptom groups from low to high.
Kellner, Hernandez, and Pathak (1992) related distinct dimensions of the SCL-90-R to different aspects of hypochondriasis. The authors observed high levels of the SCL-90-R Somatization and Anxiety scores to be predictive of hypochondriacal fears and beliefs, whereas elevations on Depression were not. Fear of disease correlated most highly with the SCL-90-R Anxiety score, but the false conviction of having a disease was more highly correlated with somatization.
The Difficult Doctor-Patient Relationship Questionnaire (DDPRQ; Hahn, Thompson, Stern, Budner, & Wills, 1994) is a relatively new instrument that can reliably identify a group of patients whose care is experienced as often difficult by physicians. The construct validity of the instrument has been established by demonstrating strong associations between characteristics that have been associated with physician-experienced difficulty. The instrument classified 11–20% of primary care patients as difficult, using a cutoff point that has been shown to distinguish between patients with difficult characteristics and those without. The DDPRQ score can also be used as a continuous measure. The instrument is available in two formats: the DDPRQ-30, a 30-item version that requires 3–5 minutes to complete, and a 10-item version, the DDPRQ-10, requiring less than 1 minute. The DDPRQ is completed by the physician after meeting with the patient.
Prior to the DDPRQ, the study of the difficult patient was limited to anecdote, clinical description, or the evaluation of idiosyncratic characteristics. Patients experienced as difficult are an important group to study because they are more likely to have psychopathology, to use the health care system disproportionately, and to be less satisfied than are patients perceived to be nondifficult when receiving care. Physicianexperienced difficulty also takes its toll on physician and health care professionals’ morale and job satisfaction (Hahn, 2000). The DDPRQ has been used in a number of studies and has proven to be an effective and reliable assessment tool.
Alcohol and Substance Abuse
It is well documented that alcohol abuse and substance abuse are often comorbid with anxiety and depressive disorders. Johnson, Brems, and Fisher (1996) compared psychopathology levels of substance abusers not receiving substance abuse treatment with those in treatment. They found SCL-90-R scores to be significantly higher for the majority of subscales for the treatment versus the nontreatment group. Drug abusers in treatment were found to have more psychological symptoms than were those not in treatment, except on the Hostility and Paranoid Ideation Scales, on which the nontreatment group had higher levels. The authors suggested that the presence of a comorbid condition is associated with a greater likelihood that drug abusers will seek treatment.
Derogatis and Savitz (2000), in their thorough analysis of the SCL-90-R, reviewed numerous studies in general medical populations in which the SCL-90-R—within the context of interview and historical data—identified alcohol and substance abusers. The authors also found that the SCL-90-R was able to identify comorbid psychopathology among substance abusers.
Shedler (2000) reviewed the Quick Psychodiagnostics Panel (QPD), which includes a 14-item alcohol and substance abuse scale. All patients answer five of the questions; the remaining questions are presented only when previous responses suggest substance abuse (i.e., logic branching). The scale is fully automated or portable and can be administered on handheld computer tablets, representing an innovation in computerized assessment. Initial diagnostic results were promising among patients enrolled in an HMO plan.
The Self-Administered Alcoholism Screening Test (SAAST) is a 37-item questionnaire that has been shown to have good reliability and validity when administered to a variety of patient samples. Patient acceptance has also been good when the use of alcohol is viewed as a health care issue. Patient endorsement of test items on the SAAST has been an excellent starting point or screening prior to a clinical interview (Davis, 2000).
Trauma and Sexual Abuse
Sexual abuse and physical abuse are factors associated with medical problems that are often overlooked. Individuals who experience such abuse also experience significant emotional distress and personal devaluation, which can lead to a chronic vulnerability and can compromise the effective treatment of their medical conditions. Many individuals who have been sexually abused exhibit clinical manifestations of anxiety or depressive disorders, without a clear understanding of the contribution made by their victim experiences (Derogatis & Savitz, 2000).
Some investigators have established the utility of the BSI in work with patients who have been sexually abused. Frazier and Schauben (1994) investigated the stressors experienced by college-age females in adjusting to the transition of college life. Significant correlations were found between the magnitude of stress and levels of psychological symptoms on the BSI. Survivors of sexual abuse had significantly higher total scores on the BSI. Coffey, Leitenberg, Henning, Turner, and Bennett (1996) also investigated the consequences of sexual abuse in 192 women with a history of childhood sexual abuse. Women who had been sexually abused revealed a higher total distress score on the BSI than did women in a nonabused control group, and a greater proportion of their BSI subscale scores fell in clinical ranges.
Toomey, Seville, Mann, Abashian, and Grant (1995) assessed a heterogeneous group of chronic pain patients and observed that those patients with a history of sexual abuse scored higher on the SCL-90-R than did nonabused patients. Similar findings were reported by Walker et al. (1995), who found that female patients with chronic pelvic pain had significantly higher symptomatic distress levels than did a patient group (tubal ligation) without pain. The mean score for chronic pelvic pain sufferers fell in the 60th percentile of psychiatric outpatient norms on the SCL-90-R. The pain group also revealed a significantly greater incidence of somaticization disorders, phobias, sexual dysfunction, and sexual abuse as compared to the no-pain group. These studies suggest chronic pain may be another condition that is associated with sexual abuse.
Quality of Life and Outcomes Research
Andrews, Peters, and Tesson (1994) indicated that most of the definitions of quality of life (QOL) describe a multidimensional construct encompassing physical affective, cognitive, social, and economic domains. QOL scales are designed to evaluate—from the patient’s point of view—the extent to which the patient feels satisfied with his or her level of functioning in the aforementioned life domains. Objective measures of QOL focus on the environmental resources required to meet one’s need and can be completed by someone other than the patient. Subjective measures of QOL assess the patient’s satisfaction with the various aspects of his or her life and thus must be completed by the patient. Andrews et al. (1994) indicated distinctions between QOL and health-related quality of life (HRQL) and between generic and condition-specific measures of QOL. QOL measures differ from HRQL measures in that the former assess the whole aspect of one’s life, whereas the latter assesses quality of life as it is affected by a disease or disorder or by its treatment. Generic measures are designed to assess aspects of life that are generally relevant to most people; condition-specific measures are focused on aspects of the lives of particular disease-disorder populations. QOL scales also provide a means to gauge treatment success. One of the more widely used QOL measures is the Medical Outcomes Study Short Form Health Status (SF-36; Ware, 1993). The scale consists of 36 items, yielding scores on eight subscales: physical functioning, social functioning, body pain, general mental health, role limitations due to emotional problems, role limitations due to physical functioning, vitality, and general health perception. New scoring algorithms yielded two new summary scales: one for physical functioning and one for mental functioning (Wetzler, Lum, & Bush, 2000).
Wallander, Schmitt, and Koot (2001) provide a thorough review of QOL issues, instruments, and applications with children and adolescents. Much of what they propose is clearly applicable to QOLmeasurement in adult patients. The authors conclude that QOLis an area that has growing importance but has suffered from methodological problems and has relied on untested instruments and on functional measurement to the neglect of the subjective experience. They offer a set of coherent guidelines about QOL research in the future and support the development of broadly constructed, universal QOL measures, constructed using people with and without identified diseases, rather than disease-specific QOL measures.
Given the expanding interest in assessing QOL and treatment outcomes for the patient, it is not surprising to see an accompanying interest in assessing the patient’s (and in some cases, the patient’s family’s) satisfaction with services received. Satisfaction should be considered a measure of the overall treatment process, encompassing the patient’s (and at times, others’) view of how the service was delivered, the capabilities and the attentiveness of the service provider, the perceived benefits of the service, and various other aspects of the service the patient received. Whereas QOL may measure the result of the treatment rendered, program evaluation may measure how the patient felt about the treatment he or she received (Maruish, 2000).
Types of Medical Settings
During the past decade, there has been an increasing interest in the assessment of health status in medical and behavioral health care delivery systems. Initially, this interest was shown primarily within those settings that focused on the treatment of physical diseases and disorders. In recent years, psychologists have recognized the value of assessing the general level of health as well.
Measures of health status and physical functioning can be classified into one of two groups: generic and conditionspecific (Maruish, 2000). An example of a generic measure assessing psychological adjustment to illness would be the PAIS (Derogatis et al., 1995). Several of these measures are listed in Table 13.1 and are reviewed by Derogatis et al. (1995) and Rozensky et al. (1997). Condition-specific measures have been available for a number of years and are used with specific medical disorders, diseases, or conditions. Some of these measures are discussed within this section and listed in Table 13.4.
General Medical Settings and Primary Care
As the primary care physician becomes the gatekeeper in many managed care and capitated health care organizations and systems, several instruments have been developed to meet the screening and assessment needs of the primary care physician. The Primary Care Evaluation of Mental Disorders (PRIMEMD; Hahn, Kroenke, Williams, & Spitzer, 2000) is a diagnostic instrument designed specifically for use in primary care by internists and other practitioners. The PRIME-MD contains separate modules addressing the five most common categories of psychopathology seen in general medicine: mood disorders, anxiety disorders, alcohol abuse and dependence, eating disorders, and somatoform disorders. The PRIME-MD has been shown to be valid and reliable, is acceptable to patients,andis oftenselectedasaresearchtoolbyinvestigators (Hahn et al., 2000). The central function of the PRIME-MD is detection of psychopathology and treatment planning. However, it can also be used in episodic care, in subspecialty consultations, and in consultation-liaison psychiatry and health psychology assessments.
The COMPASS for Primary Care (COMPASS-PC; Grissom & Howard, 2000) is also a valid and reliable instrument designed for internists and primary care physicians. Within the instrument’s 68 items are three major scales—Current WellBeing (CWB), Current Symptoms (CS), and Current Life Functioning(CLF).Thefour-itemCWBscaleincludesitemson distress, energy and health, emotional and psychological adjustment, and current life satisfaction. The 40-item CS scale contains at least three symptoms from each of seven diagnoses—depression, anxiety, obsessive-compulsive disorder, adjustment disorder, bipolar disorder, phobia, and substanceabusedisorders.The24-itemCLFrepresentssixareasof life functioning—self-management, work-school-homemaker, social and leisure, intimacy, family, and health (Grissom & Howard, 2000). Like the PRIME-MD, the COMPASS-PC can be easily administered over various intervals of treatment.
Some of the brief instruments discussed earlier are also appropriate for general medical settings. These include the QPD, SCL-90-R, and the SF-36.
In their review of adaptation to chronic illness and disability, Livneh and Antonak (1997) discuss frequently used general measures of adaptation to illness such as the PAIS (Derogatis et al., 1995). The authors also discuss several unidimensional, general measures of adaptation to disability as well. Numerous condition-specific measures have been developed in various medical specialty areas. For example, several measures of adaptation to specific conditions have been developed in oncology (Shapiro et al., 2001), in cardiology (Derogatis & Savitz, 2000), in rehabilitation medicine (Cushman & Scherer, 1995), for AIDS-HIV patients (Derogatis & Savitz, 2000), for sleep disorders (Rozensky et al., 1997), for diabetes (Rubin & Peyrot, 2001), for pain treatment (Cushman & Scherer, 1995), for geriatric patients (Scogin, Rohen, & Bailey, 2000), in emergency medicine (Rozensky et al., 1997), in neurology (Livneh & Antonak, 1997), and in renal dialysis (Derogatis & Savitz, 2000). Examples of these measures are listed in Table 13.4.
When considering general measures of adaptation or condition-specific measures, the determination of which to use can be based upon the specific referral question posed to the psychologist. If the referral question involves whether the patient’s psychological distress is significant enough to warrant clinical intervention, then a general measure of adaptation will be clinically useful and sufficient. However, if the referral question concerns the quality of a patient’s adjustment to a specific illness at a particular stage of that illness compared with the typical patient with that illness, then a conditionspecific measure—if available—may be more meaningful. Quality of life constructs combine normative data from both general and illness-specific populations. Researchers such as Derogatis et al. (1995) support the use of a modular strategy, combining general instruments with modules developed from illness-specific samples. In this way, an illness-specific measure can be used as an additional domain of the general instrument or as a distinct, stand-alone measure.
As can be seen from the broad range of topics covered within this research paper, psychological assessment in medical settings is diverse and can in some instances be highly specialized. The individuals practicing in these settings may prefer the professional identity of clinical psychologist, clinical health psychologist, or clinical neuropsychologist. All three of these specialists have a place in performing formal assessments within medical settings, with the latter two being more specialized with regard to particular medical populations and specific medical disorders. With regard to training and employment, medical settings have played an important historical role in the development of psychological assessment and will likely continue to do so in the future.
Future developments in the area of psychological assessment in medical settings will center around such concepts as specificity, brevity, and normative standards for particular medical populations. Assessments will be targeted to address specific outcome and quality-of-life questions rather than general psychological status and will be utilized across large health care systems as well as with specific disease entities. This goal will require more precise development of specific normative standards for specific, well-defined patient groups and subgroups. Because of economic pressures, including the need to see patients for less time and to see a greater number of patients, there will continue to be a pressure on test authors and publishers to create short forms and shorter instruments. As the former trend continues to take place, we must bear in mind the psychometric costs associated with accompanying threats to validity (Smith, McCarthy, & Anderson, 2000). Psychological assessment will become incorporated in costutility analysis, as outcomes involving patient adjustment, well-being, and quality of life become more central and quantifiable as part of the economic dimensions of treatment (Kopta, Howard, Lowry, & Beutler, 1994). Brevity, costefficiency, minimal intrusiveness, and broader applicability will be salient concepts in the design of future assessment systems (Derogatis et al., 1995).
Although it has been recommended for many years that clinician-based judgments yield to actuarial or mechanical judgments (cf. Grove, Zald, Lebow, Snitz, & Nelson, 2000), and without question there has been a useful trend in this direction of at least partial reliance on empirically derived decision aids, we do not foresee a time in the near future when clinicians will abrogate their assessment roles completely to actuarial or mechanical methods. This position is not based on philosophical or scientific disagreement with the relevant decision-making literature; rather, it is based on the belief that a sufficient number of appropriate mechanical algorithms will continue to be lacking for years to come (cf. Kleinmuntz, 1990).
Computer-administered assessment, as well as planning for treatment and prevention, will likely be an important component of the future in psychological assessment in medical settings, as has been suggested regarding psychological assessment in general (Butcher, Perry, & Atlis, 2000; Garb, 2000; Snyder, 2000). Maruish (2000) sampled several computerized treatment and prevention programs involving depression, obsessivecompulsive disorders, smoking cessation, and alcohol abuse. Symptom rating scales, screening measures, diagnostic interviews, and QOL and patient satisfaction scales already have been or can easily be computerized, making administration of these measures efficient and cost-effective. As computer technology advances with interactive voice response (IVR), new opportunities for even more thorough evaluation exist. However, as computer usage and technology develop, so do concerns about patient confidentiality, restricting access to databases, and the integration of assessment findings into effective treatment interventions. Similarly, Rozensky et al. (1997) predicted that there will be less emphasis placed on the diagnosis of psychopathology and more focus on those computerized assessment procedures that directly enhance planning and evaluating treatment strategies. Moreover, as telemedicine or telehealth develops, psychological assessment will need to be an integral part of patient and program evaluation as distance medicine technologies improve continuity of care.
Assessment in medical settings will likely continue to become even more specialized in the future. With this trend, more attention will be paid—both within the discipline and by test publishers—to test user qualifications and credentials (cf. Moreland, Eyde, Robertson, Primoff, & Most, 1995). In this same vein, more specific guidelines will be developed to aid in dealing with difficult ethical and legal dilemmas associated with assessment practices with medical patients, as is already evident within clinical neuropsychology (e.g., Johnson-Greene et al., 1997; Sweet, Grote, & Van Gorp, 2002).
Illness and disability necessitate change, resulting in continuous modification in coping and adjustment by the patient, his or her family, and medical personnel (Derogatis et al., 1995). Psychology’s ability to document accurately the patient’s response to disease and treatment-induced change is crucial to achieving an optimal treatment plan. Psychological assessment can be an integral part of the patient’s care system and will continue to contribute crucial information to the patient’s treatment regimen. Carefully planned, programmatic, integrated assessments of the patient’s psychological coping and adjustment will always serve to identify problematic patients as well as those well-adjusted patients who are entering problematic phases of illness and treatment. Assessments that identify taxed or faltering coping responses can signal the need for interventions designed to avert serious adjustment problems, minimize deterioration of well-being, and restore patient QOL. Cost-effectiveness of medical interventions will continue to be enhanced by appropriate use of psychological assessment in medical settings.
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