1 Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists...
-
Upload
nathan-larson -
Category
Documents
-
view
215 -
download
1
Transcript of 1 Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists...
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
16
17
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
18
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
19
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
20
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
21
22
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)
23
Implications
• Categorical status implies tight etiological net (biological?), dimensional a looser etiology (multidetermined?)
• Dimensional disorders unlikely to respond well to any one treatment
24
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