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Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists

Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists. Robert E. McGrath, Ph.D. Fairleigh Dickinson University. Topics. Enhancing Adherence Specificity in Problem Identification The Structure of Clinical States. Enhancing Adherence.

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Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists

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  1. Integrating Psychological Assessment with Pharmacotherapy:A New Direction for Psychologists Robert E. McGrath, Ph.D. Fairleigh Dickinson University

  2. Topics • Enhancing Adherence • Specificity in Problem Identification • The Structure of Clinical States

  3. Enhancing Adherence • Medication adherence about 50% (Haynes et al., 2002) • Research on improving adherence involves multidimensional interventions (McDonald et al., 2002) • 25% of non-adherent patients (never got Rx) reported they were adherent (Kobak et al., 2002)

  4. Lack of Effectiveness? • Antidepressant effectiveness questionable (Kirsch et al., 2002, Prevention & Treatment) • Overprescribing for mental disorders • PCPs: approx. 100% (National Depressive and Manic Depressive Association, 2000) • Psychiatrists: approx. 90% (Pincus et al., 1999) • Psychologists: 15%? (John L. Sexton, personal communication, August 4, 2000; Wiggins & Cummings, 1998) • Still likely many people do not adhere for whom medication would be effective (anxiety, psychosis)

  5. Predicting Non-Adherence: Personality Approach • Do personality factors predict adherence? • NEO-PI (Costa & McCrae, 1992): Neuroticism, Extraversion, Openness to Experience, Conscientiousness, Agreeableness • Predicts adherence to psychotherapy (Miller, 1991; Muten, 1991), weight loss (Galluccio-Richardson et al., 2003), and kidney medication (Christensen & Smith, 1995): • Small but significant effect for Conscientiousness and Rx regimen

  6. Predicting Adherence: Social Approach • Do social factors predict adherence? • Theory of Planned Behavior (Ajzen, 1988):

  7. Predicting Adherence: Attitudinal Approach • Predicts adherence to drug abuse treatment (Kleinman et al., 2002), weight loss (Mancini et al., 2002), and psychiatric medications (Conner et al., 1998): • Three attitudinal factors accounted for 65% of variability in intention to adhere to meds; two factors accounted for 38% of variability in behavior

  8. Factors Affecting Rx Adherence • Ineffectiveness/preference for another medication • Personality factors: responsibility/conscientiousness, resistance to authority • Attitudinal factors • Cost/reimbursement • Anxiety about side effects • Side effects • Inadequate understanding: latency, duration • Chaotic life circumstances

  9. Therapeutic Assessment • Developed as a model for collaborative assessment consultation (Finn, 1996). • RCT found TA reduced general distress (d = .80), and improved self-esteem (1.04) and hopefulness (.84) when compared to attention placebo (Finn & Tonsager, 1992)

  10. Initial Interview • Build rapport • Introduce information-gathering and decision-making as a collaboration • Listen attentively • Frame questions collaboratively • Include whether medication is appropriate • Explicitly encourage questions about medications • Collect background information • Begin with information relevant to questions • Ask permission for additional questioning and explain why you need it • Explore issues likely to impeded adherence • Ask about resistance/incomplete participation

  11. Initial Interview • Ask about past medication experiences • Show genuine interest • Empathize with previous experiences/hurts • State shortcomings of previous experiences • Offer contract that addresses previous hurts • Ask to be alerted if patient feels mistreated • Offer tentative answers • Invite modification • Invite questions • Encourage future questioning • Complete the prescription • Initiate treatment • Monitoring • Contract about contact

  12. Conclusions • Prescriptions are a medical issue; prescribing is an interpersonal one • Psychologists’ use of assessment can potentially improve adherence (and therefore, it is hoped, outcomes) • Psychologists’ understanding of humanistic and interpersonal principles can potentially improve adherence and outcomes

  13. Specificity in Problem Identification • Actuarial versus clinical prediction and description • Meehl (1954, 1956) • Superiority of actuarial methods (Grove et al., 2000) • Cognitive errors (Arkes, 1981) • Covariance misestimation • Hindsight bias

  14. Restructured Clinical Scales • Affect research suggests that the discrimination of clinical states is muddied by the common Demoralization factor (Tellegen, 1985) • RCSs consist of a measure of Demoralization, and scale-relevant items that are relatively independent of demoralization

  15. Conclusions • Assessment can improve the accuracy of diagnosis and therefore treatment • Increasing specificity in assessment instruments can enhance decision-making • Functional components of clinical state may be more useful than diagnosis

  16. The Structure of Clinical States • DSM assumes a categorical (biological) model • Comorbidity • NOS and mixed categories • Subclinical categories • Assessors often assume dimensionality based on psychometric considerations • Neither is universally correct

  17. Taxometric Analysis • Developed by Meehl and associates (Meehl & Yonce, 1994; Waller & Meehl, 1998) • Identified several patterns that would emerge in relationships between measures only if their shared latent construct is categorical

  18. MAXCOV (Maximum Covariance) • Three measures of latent variable η • Sample divided into sequential subsets on X • Covariance of Y and Z computed within each subset • A graph of covariances should make an inverted U only if η is categorical

  19. Findings for Diagnosis • Schizoid spectrum disorders seem categorical (Blanchard, Gangestad, Brown, & Horan, 2000; Erlenmeyer-Kimling, Golden, & Cornblatt, 1989) • Melancholia appears categorical (Ambrosini, Bennett, Cleland, & Haslam, 2002; Haslam & Beck, 1994) • Unipolar, non-melancholic depression consistently dimensional (Franklin, Strong, & Greene, 2002; Ruscio & Ruscio, 2000, 2002)

  20. Implications • Categorical status implies tight etiological net (biological?), dimensional a looser etiology (multidetermined?) • Dimensional disorders unlikely to respond well to any one treatment

  21. Discussion • Prescribing is a complex interpersonal act • Case formulation and analysis of treatment outcomes may be enhanced by specificity in characterization of clinical states • A greater understanding of clinical states may overcome biological assumptions suggesting unimodal treatments • Opportunities for scientist-practitioners

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