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

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Presentation on theme: "1 Integrating Psychological Assessment with Pharmacotherapy: A New Direction for Psychologists Robert E. McGrath, Ph.D. Fairleigh Dickinson University."— Presentation transcript:

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

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

3 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 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 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 6 Predicting Adherence: Social Approach Do social factors predict adherence? –Theory of Planned Behavior (Ajzen, 1988):

7 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 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 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 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 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 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 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 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

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17 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 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 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 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

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22 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 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 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

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