Psychiatric co-morbidities with neuropsych referrals

[Therapist4Chnge]

I've experienced an uptick in referrals of cases that have strong psychiatric histories with mostly incidental neurologic changes/injury, which has caused me to augment my typical battery of assessments. I'm curious if others have seen/experienced this? What psych measures do you use? I've found myself swapping out the BHI-2 for the MMPI-2RF. I already utilize a variety of embedded and stand-alone validity measures, so those all stay. Do you change your cognitive battery? I end up truncating some of my selections bc of time concerns. I vastly prefer to keep my (somewhat) flexible battery intact, though w. psych heavy cases it is much harder to do.

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[DynamicDidactic]

definitely the Rorschach

 

[Therapist4Chnge]

*face palm*

 

[WisNeuro]

SIMS, MMPI-RF.But, I'm in the VA, psych/effort go hand in hand.

 

[AcronymAllergy]

When there's a stronger psych component, I'll usually go with the RF, as most folks seem to get through it pretty quickly. I'll usually also spend a bit longer on related areas in my interview. Like you, I haven't yet regularly truncated my cognitive battery in these cases, but if the pt knocks a test or two out of the park, I may forego additional tests of those same skills.

And also like you, I'm seeing more and more psychiatrically-complex cases. Same goes with complex medical history/problems. And, like WisNeuro mentioned in his other thread, complex medication cocktails. I don't think I've had a single straightforward, "yep, looks like amnestic MCI/early Alzheimer's" case since I started this job.

Diagnostically, it honestly sometimes makes me feel a bit useless. But in those instances, I try to refocus on the recommendations, and conveying some semblance of useful information both in the report and during feedback.

 

[Therapist4Chnge]

When there's a stronger psych component, I'll usually go with the RF, as most folks seem to get through it pretty quickly. I'll usually also spend a bit longer on related areas in my interview. Like you, I haven't yet regularly truncated my cognitive battery in these cases, but if the pt knocks a test or two out of the park, I may forego additional tests of those same skills.

I don't mind truncated the WMS-IV bc there are data to support not administering the entire thing, though for some cases I prefer to have more data from it.

Diagnostically, it honestly sometimes makes me feel a bit useless. But in those instances, I try to refocus on the recommendations, and conveying some semblance of useful information both in the report and during feedback.

I think where we are most useful is w. Recommendations. I think we often under value this area of our knowledge. I survey my top referring docs each yr about the consult process and my documentation, and consistently I'm told that the most useful part of what I/we do is educate about various disorders and cognition, in addition to provide "next steps" for the provider and patient. Some of it isn't Rocket Surgery, but having us also document the recs can help w. Buy-In.

I recently wrote an Eval where the Dx was unclear, but the Recs would help fill in some of the blanks: referrals for further eval, rule out certain DX's, provide some things like stress management to work on while the med piece is sorted. I was frank about the uncertainty bc of the psych overlay and inconsistent (outside) med evals; the provider was actually ok w it bc they at least had more ideas about what to look at next.

 

[PsyDr]

I tend to use a relatively short battery anyway, which is expanded as needed. Psychiatric patients get the same, but is only expanded in terms of the interview. IMO, the utility of a such a referral is 1) to reassure the pt that they are not "losing their mind", 2) negatively reinforce future cognitive complaints, 3) prevent iatrogenesis of a somatoform disorder.

 

[smalltownpsych]

As a consumer of neuropsychological assessments myself I agree that the recs are exceptionally important. I hate the long list of cut and paste recs that some psychologists do. I am looking for some specific help with this patient. As a former clinical director, I reviewed all the testing for referrals to our facility and then had to begin formulating an academic and treatment plan. At times I found myself having to go through the testing results myself and coming up with my own recommendations. I much preferred it when I could just print out the recs page and highlight the academic stuff for the teachers and review the treatment recs with the therapist as we began formulating treatment plans. Fortunately, my experience has been that most psychologists were of the latter variety. When conducting assessments myself, I personally try to key on a few of the most important and easily implemented recommendations because I feel that maximizes chance of follow through. I also put the most important one first.

 

[WisNeuro]

Level of specificity in recs is going to vary significantly depending on the referral. Is it for diagnostic clarity (what kind of dementia) or a grab bag of psych and cog complaints? The former is going to be fairly boilerplate (e.g., get an AD on file, get connected with social work, yadda yadda). Also, I'd say it depends on what kind of institution you are in. When it get referrals from other mental health professionals, I usually talk with them face to face about the results, so I may not need to have 2 pages of drawn out recs.

 

[smalltownpsych]

Level of specificity in recs is going to vary significantly depending on the referral. Is it for diagnostic clarity (what kind of dementia) or a grab bag of psych and cog complaints? The former is going to be fairly boilerplate (e.g., get an AD on file, get connected with social work, yadda yadda). Also, I'd say it depends on what kind of institution you are in. When it get referrals from other mental health professionals, I usually talk with them face to face about the results, so I may not need to have 2 pages of drawn out recs.

Actually when we had questions that weren't clear from the testing, it tended to be more in the realm of their level of social functioning or aggressive behaviors so we usually spoke with the previous treating therapist. That was a mixed bag of results too. These assessments were all being done for placement and educational planning after a short-term inpatient or short-term therapeutic wilderness program. Interesting and profitable work for the psychologists doing the testing.