The Use of Psychological Testing for Treatment Planning and Outcomes Assessment

Volume 1: General Considerations

Mark E. Maruish

• Publisher: Routledge
• Year: 2004
• Print ISBN: 9780805843293
• eBook ISBN: 9781135630577
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Test-based psychological assessment has been significantly affected by the health care revolution in the United States during the past two decades. Despite new limitations on psychological services across the board and psychological testing in particular, it continues to offer a rapid and efficient method of identifying problems, planning and monitoring a course of treatment, and assessing the outcomes of interventions.

This thoroughly revised and greatly expanded third edition of a classic reference, now three volumes, constitutes an invaluable resource for practitioners who in a managed care era need to focus their testing not on the general goals of personality assessment, symptom identification, and diagnosis so often presented to them as students and trainees, but on specific questions: What course of treatment should this person receive? How is it going? Was it effective?

New chapters describe new tests and models and new concerns such as ethical aspects of outcomes assessment. Volume I reviews general issues and recommendations concerning the use of psychological testing for screening for psychological disturbances, planning and monitoring appropriate interventions, and the assessing outcomes, and offers specific guidelines for selecting instruments. It also considers more specific issues such as the analysis of group and individual patient data, the selection and implementation of outcomes instrumentation, and the ethics of gathering and using outcomes data. Volume II discusses psychological measures developed for use with younger children and adolescents that can be used for the purposes outlined in Volume I; Volume III, those developed for use with adults.

Drawing on the knowledge and experience of a diverse group of leading experts--test developers, researchers, clinicians and others, the third edition of The Use of Psychological Testing for Treatment Planning and Outcomes Assessment provides vital assistance to all clinicians, and to their trainees and graduate students.

1
Introduction

Mark E.Maruish
Southcross Consulting

The cost of health care in the United States has reached astronomical heights. In 1995, approximately $1 trillion, or 14.9% of the gross domestic product (GDP), was spent on health care (“Future Targets,” 1996). In 1998, these costs increased to $1.1 trillion and accounted for 13.5% of the GDP (see Levit et al., 2000). These costs rose to $1.31 trillion (13.3% of the GDP) in 2000, and then increased 8.7% to $1.42 trillion (14.1 % of the GDP) in 2001 (“Health Care Costs,” 2003). The most recent projections are that between 2001 and 2011 the national health expenditures will grow at an average annual rate of 7.3%, or 2.5% faster that the GDP (Centers for Medicare and Medicaid Services, 2002). Thus, it is estimated that by 2011, health care costs will reach $2.8 trillion, or approximately 17% of the GDP.

The costs of mental health and substance abuse problems also have risen over the past several years and are particularly disconcerting. A Substance Abuse and Mental Health Services Administration (SAMHSA) summary of various findings in the literature indicated that America’s bill for mental health disorders in 1990 was $148 billion (Rouse, 1995). This compares to the 1983 direct and indirect mental health costs of $73 billion reported by Harwood, Napolitano, and Kristiansen (cited in Kiesler & Morton, 1988). The Surgeon General’s report on mental health indicated that in 1996 $69 billion (7.3% of the total spending on health care) could be attributed to direct mental health services, $12.6 billion to substance abuse treatment, and $17.7 billion to treatment for Alzheimer’s and other dementias (Surgeon General of the United States, 1999). All told, these expenditures represented 10.5% of the total health care cost of $943 billion for 1996. This does not include indirect costs, which most recently (1990) were estimated to be $78.6 billion for mental health disorders.

The high cost of treating behavioral health problems is not surprising, given the prevalence of psychiatric and substance use disorders in this country. Based on the findings from the Epidemiologic Catchment Area (ECA) study conducted in the early 1980s (Regier et al, 1993) and the National Comorbidity Study (NCS) of the early 1990s (Kessler et al., 1994), the Surgeon General (1999) estimated the following one-year prevalence rates for adults 18–54 years old:

• Nineteen percent have a mental health disorder.
• Nine percent have a mental health disorder accompanied by significant functional impairment.
• Six percent have an addictive disorder.
• Three percent have both mental health and addictive disorders. Twenty-eight to thirty percent have either a mental health or addictive
• Twenty-eight to thirty percent have either a mental health or addictive disorder.

The Surgeon General also estimated that 20% of children 9–17 years old have a mental health or substance abuse disorder with at least mild functional impairment, while 20% of adults 55 years or older have a mental health disorder. Four percent of Americans 55 years or older were said to have a mental disorder accompanied by significant functional impairment.

The 2001 National Household Survey on Drug Abuse (NHSDA; Substance Abuse and Mental Health Services Administration [SAMHSA], 2002) reveals further details about the prevalence of mental health and substance abuse disorders. The results of this survey indicated that 7.3% of individuals 18 years or older had a DSM-IV disorder accompanied by functional impairment. In addition, 7.3% of individuals 12 years or older were classified with abuse of or dependence on alcohol or illicit drugs.

THE VALUE OF BEHAVIORAL HEALTH CARE SERVICES

The need for behavioral health care services is great. Unsurprisingly, the demand for mental health and substance abuse services also is significant. According to the Surgeon General’s (1999) report, 15% of the adult population and 21% of children and adolescents use mental health services in a given year. About half of the 15% of adults have a diagnosed mental health or addictive disorder, and the remainder are said to have a mental health “problem.” The NHSDA report (SAMHSA, 2002) indicates that during the previous year, 11% of individuals 18 years or older and 18% of individuals 12–17 years old received mental health treatment. These represent significant (p<.01) increases from the previous year’s estimates. Also, an estimated 1.4% of the population 12 years or older receive treatment for substance use. But what is the value of the services provided to those suffering from mental illness or substance abuse/dependency? Some might argue that the benefit from these services is either minimal or too costly to achieve if significant effects are to be gained. This claim, however, is at odds with data that indicate otherwise.

Numerous studies have demonstrated that treatment of mental health and substance abuse/dependency problems can result in substantial savings when viewed from a number of perspectives. This “cost offset” effect has been demonstrated most clearly in savings in medical care dollars. Given reports that 50–70% of typical primary care visits are for medical problems that involve psychological factors, the value of medical cost offset is significant (American Psychological Association, 1996). Moreover, the American Psychological Association also reported that 25% of patients seen by primary care physicians have a disabling psychological disorder and that depression and anxiety rank among the top six conditions dealt with by family physicians.

Following are just a few of the findings supporting the medical cost savings that can be achieved through the provision of behavioral health care treatment:

• Patients with diagnosable behavioral disorders who are seen in primary care settings use 2 to 4 times as many medical resources as patients without these disorders (“Leaders Predict,” 1996).

• A study by Simon, Von Korff, and Barlow (1995) revealed that the annual health care costs of 6/000 primary care patients with identified depression were nearly twice those of the same number of primary care patients without depression ($4,246 vs. $2,371).

• Johnson, Weissman, and Klerman (1992) reported that depressed patients make 7 times as many visits to emergency rooms as nondepressed patients.

• Saravay, Pollack, Steinberg, Weinschel, and Habert (1996) found that cognitively impaired medical and surgical inpatients were rehospitalized twice as many times as cognitively unimpaired patients within a 6-month period. In the same study, depressed medical and surgical inpatients were found to have an average of approximately 12 days of rehospitalization over a 4-year follow-up period. During this same period, nondepressed inpatients averaged only 6 days of rehospitalization.

• Demonstrating the potential for additional costs that can accrue from the presence of a behavioral health problem, a longitudinal study found the health care costs of families with an alcoholic member to be twice that of families without alcoholic members (Holder & Blose, 1986).

• Sipkoff (1995) reported several conclusions drawn from a review of several studies conducted between 1988 and 1994 and listed in the “Cost of Addictive and Mental Disorders and Effectiveness of Treatment” report published by the Substance Abuse and Mental Health Services Administration (SAMHSA). One conclusion derived from a meta-analysis of the cost-offset effect was that treatment for mental health problems results in about a 20% reduction in the overall cost of health care. The report also concluded that although alcoholics were found to spend twice as much on health care as those without abuse problems, one-half of the cost of substance abuse treatment is offset within one year by subsequent reductions in the combined medical costs for the patient and his or her family.

• Strain et al. (1991) found that screening a group of 452 elderly hip-fracture patients for psychiatric disorders prior to surgery and then providing mental health treatment to the 60% of the sample needing treatment reduced total medical expenses by $270,000. The cost of the psychological/psychiatric services provided to this group was only $40,000.

• Simmons, Avant, Demski, and Parisher (1988) compared the average medical costs for chronic back pain patients at a multidimensional pain center (providing psychological and other types of intervention) incurred during the year prior to treatment to those costs incurred in the year following treatment. The pretreatment costs per patient were $13,284 while posttreatment costs were $5,596.

APA (1996) succinctly summarized what appear to be the prevalent findings of the medical cost-offset literature:

• Patients with mental disorders are heavy users of medical services, averaging twice as many visits to their primary care physicians as patients without mental disorders.
• When appropriate mental health services are made available, heavy use of the system often decreases, resulting in overall health savings.
• Cost-offset studies show a decrease in total health care costs following mental health interventions even when the cost of the intervention is included.
• In addition, offset increases over time, largely because…patients continue to decrease their overall use of the health care system, and don’t require additional mental health services, (p.)

A more detailed discussion of various ways in which behavioral interventions can both maximize care to medical patients and achieve significant economic gains can be found in the work of Friedman, Sobel, Myers, Caudill, and Benson (1995).

The dollar savings that result from medical cost offset are relatively obvious and easy to measure. However, the larger benefits to the community—financial and otherwise—that can also accrue from the treatment of mental health and substance abuse/ dependency problems may not be as obvious. One area in which treatment can have a tremendous impact is in the workplace. For example, note the following facts compiled by the American Psychological Association (1996):

• In 1985, behavioral health problems resulted in over $77 billion in lost income to Americans.
• California’s stress-related disability claims totaled $380 million in 1989.
• In 1980, alcoholism resulted in over 500 million lost workdays in the United States.
• Major depression cost an estimated $23 billion in lost workdays in 1990.
• Individuals with major depression are 3 times more likely than nondepressed individuals to miss time from work and 4 times more likely to take disability days.
• Seventy-seven percent of all subjects from 58 psychotherapy effectiveness studies focusing on the treatment of depression received significantly better work evaluations than depressed subjects who did not receive treatment.
• Treatment resulted in a 150% increase in earned income for alcoholics and a 390% increase in income for drug abusers in one study of 742 substance abusers.

On another front, the former director of Office of National Drug Control Policy reported that for every dollar spent on drug treatment, America saves $7 in health care and criminal justice costs (“Brown Resigns,” 1995). Also, SAMHSA’s summary of the literature on 1990 behavioral health care costs indicated that crime, criminal justice activities, and property loss associated with crime stemming from substance use and mental disorders resulted in a total of $67.8 billion spent or lost (Rouse, 1995).

These and several other similar findings have been used to support the assertion that the costs associated with the identification and treatment of behavioral health problems is money well spent. At the same time, it appears that the case is not totally clear-cut, at least as far as medical cost offset is concerned. In fact, based on their review of over 25 mental health-offset cost studies published between 1965 and 1995, Sperry, Brill, Howard, and Grissom (1996) determined the following:

The only conclusion to come from research on cost-offset due to mental health treatment is that there is no clear-cut indication of cost savings. Studies that claim such an effect are often methodologically flawed. The same design problems also cast doubt on the findings of studies that claim to find no cost-offset effect. Future research needs stronger methodology to be considered valid. (pp.)

The truth of the matter probably lies somewhere in the middle.

Society’s need for behavioral health care services provides an opportunity for psychologists and other trained behavioral health service providers to become part of the solution to a major health care problem that shows no indication of decline. Each of the helping professions has the potential to make a contribution to this solution. Not the least are those contributions that can be made by psychologists and others trained in the use of psychological tests.

For decades, psychologists and other behavioral health care providers have come to rely on psychological assessment as a standard tool to assist diagnostic and treatment-planning activities. However, the care delivery system that has evolved within health care in general and behavioral health care services in particular has led to changes in how third-party payers, psychologists, and other service providers think about and/or use psychological assessment in day-to-day clinical practice. Some question the value of psychological assessment in the managed behavioral health care arena. Others argue that it is in just such an arena that the benefits of psychological assessment can be most fully realized and contribute significantly to the delivery of cost-effective treatment for behavioral health disorders (Maruish, 1999), Consequently, assessment could assist the health care industry in appropriately controlling or reducing the utilization and cost of health care over the long term. As Maruish (1990) observed well over a decade ago:

Consider that the handwriting on the wall appears to be pointing to one scenario. With limited dollars available for treatment, the delivery of cost-efficient, effective treatment will be dependent on the ability to clearly identify the patient’s problem(s). Based on this and other considerations, the most appropriate treatment modality…must then be determined. Finally, the organization will have to show that it has met the needs of each client…. It is in all of these functions—problem identification, triage/disposition, and outcome measurement—that psychological assessment can make a significant contribution to the success of the organization, (p.)

It is the latter side of the argument that is supported by this author and provides the basis for this and the subsequent chapters within this work.

As a final introductory note, it is important for the reader to understand that the term psychological assessment, as it is used in this chapter, refers to the evaluation of a patient’s mental health status using psychological tests or related instrumentation. This evaluation may be conducted with or without the benefit of patient or collateral interviews, review of medical or other records, and/or other sources of relevant information about the patient.

THE PRACTICE OF PSYCHOLOGICAL ASSESSMENT IN THE AGE OF MANAGED BEHAVIORAL HEALTH CARE

Probably in no other period has so much progress in the field of health care taken place than during the past century Breakthroughs and technological advances in the diagnosis, treatment, and prevention of diseases abounded in this 100 years. On the other hand, never has there been so much controversy, debate, and upheaval surrounding this country’s health care del...

Table of contents

• COVER PAGE
• TITLE PAGE
• COPYRIGHT PAGE
• PREFACE
• LIST OF CONTRIBUTORS
• 1. INTRODUCTION
• 2. SCREENING FOR PSYCHIATRIC DISORDERS
• 3. USE OF PSYCHOLOGICAL TESTS/INSTRUMENTS FOR TREATMENT PLANNING
• 4. ASSESSMENT AS INTERVENTION WITHIN THE TRANSTHEORETICAL MODEL
• 5. USE OF PSYCHOLOGICAL TESTS FOR ASSESSING TREATMENT OUTCOMES
• 6. GUIDELINES FOR SELECTING PSYCHOLOGICAL INSTRUMENTS FOR TREATMENT PLANNING AND OUTCOMES ASSESSMENT
• 7. DEVELOPMENT AND IMPLEMENTATION OF A BEHAVIORAL HEALTH OUTCOMES PROGRAM
• 8. PROGRESS AND OUTCOMES ASSESSMENT OF INDIVIDUAL PATIENT DATA: SELECTING SINGLE-SUBJECT DESIGN AND STATISTICAL PROCEDURES
• 9. SELECTING STATISTICAL PROCEDURES FOR PROGRESS AND OUTCOMES ASSESSMENT: THE ANALYSIS OF GROUP DATA
• 10. ETHICS CONCERNS IN OUTCOMES ASSESSMENT
• 11. FUTURE DIRECTIONS IN THE USE OF PSYCHOLOGICAL ASSESSMENT FOR TREATMENT PLANNING AND OUTCOMES ASSESSMENT: PREDICTIONS AND RECOMMENDATIONS