Is this what therapy has become for many?

[BuckeyeLove]

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I had an interesting moment the other day while working with an acute patient at my hospital. This particular patient has a longitudinal history of debilitating schizophrenia even whilst medicated, and most, if not all of his family has left him high and dry. Consequently, all he has essentially is my hospital and his outpatient team and therapist. We had a tele-psych video conference with his outpatient therapist, who is a LISW, and she wanted to do a “therapy” session with him. I got to see this “therapy” session as I had to be in the room to aid in using the video equipment.


What this session essentially amounted to was her going through an ISP and them just talking about if goals had been met or not. That was it. No actual intervention. No actual therapy. There were many moments where there was legitimate therapeutic grist for the mill (as one of my old supervisors use to call them), and she literally missed all of them and was just a robot going through a checklist. I almost wanted to commandeer the session, but felt that would have been a bit too cluster b of me in that moment.


I guess what I’m wondering is… is this what therapy has become for folks in this community mental health centers? Checklists of ISPs? It brought me back to when I trained at one and I remember that’s all they really cared about, not actually doing real work. And I know often these folks will be intermittent in their session attendance, or only attend one session, but I was trained that even in those circumstances, legitimate therapeutic work can occur with benefit. It also highlighted to me (at least superficially) the differences between doctoral level services and what I have seen a lot of master’s level folks provide (not all, but many). At the end of it I just felt bad for this man, as he had been looking forward to the meeting (he’s been stuck on a unit since March because of COVID), and he just appeared let down and deflated subsequent to their session. Anyways….rant over.

 

[WisNeuro]

Pretty much. In my first sessions with people, I always ask about their previous experiences with therapy. Most have had bad experiences. When they tell me what therapy entailed for them, it's pretty clear no actual therapy was being done, or it was "supportive therapy" with no discernable goal, or checking in on goals. Particularly with midlevel providers.

 

[MAClinician]

I guess what I’m wondering is… is this what therapy has become for folks in this community mental health centers? Checklists of ISPs? It brought me back to when I trained at one and I remember that’s all they really cared about, not actually doing real work. And I know often these folks will be intermittent in their session attendance, or only attend one session, but I was trained that even in those circumstances, legitimate therapeutic work can occur with benefit. It also highlighted to me (at least superficially) the differences between doctoral level services and what I have seen a lot of master’s level folks provide (not all, but many). At the end of it I just felt bad for this man, as he had been looking forward to the meeting (he’s been stuck on a unit since March because of COVID), and he just appeared let down and deflated subsequent to their session. Anyways….rant over.

In the land of CMHC’s, the amount of administrative paperwork is overwhelming and redundant. Often driven by insurance requirements (Medicaid and/or Medicare). At the previous CMHC I worked at, in a fee for service model, you didn’t get paid for your session if the paperwork wasn’t also turned in/completed. And our state Medicaid required treatment plan reviews every 3 months (signed by the client). Insurance doesn’t pay for completing paperwork so admin’s solution is to tell the clinicians to do it in session with the client. (What person wants to see 20+ clients a week and then complete 15 or more hours of paperwork on top of that?)On the one hand it helps with collaborative treatment planning but on the other hand it takes up session time that could be used for the actual treatment. It sucks for the client and for the clinician. That has been my experience at least. Other states/regions may have different policies. I have also seen crappy clinicians as well so I don’t doubt you saw a combination of the two issues. Unfortunate for the client.

 

[Sanman]

In the land of CMHC’s, the amount of administrative paperwork is overwhelming and redundant. Often driven by insurance requirements (Medicaid and/or Medicare). At the previous CMHC I worked at, in a fee for service model, you didn’t get paid for your session if the paperwork wasn’t also turned in/completed. And our state Medicaid required treatment plan reviews every 3 months (signed by the client). Insurance doesn’t pay for completing paperwork so admin’s solution is to tell the clinicians to do it in session with the client. (What person wants to see 20+ clients a week and then complete 15 or more hours of paperwork on top of that?)On the one hand it helps with collaborative treatment planning but on the other hand it takes up session time that could be used for the actual treatment. It sucks for the client and for the clinician. That has been my experience at least. Other states/regions may have different policies. I have also seen crappy clinicians as well so I don’t doubt you saw a combination of the two issues. Unfortunate for the client.

I do agree that paperwork can be cumbersome. That said, I have seen 20+ medicaid/ medicare clients/wk for years and provided good therapy. 20 clients plus 15 hours paperwork is just a full-time job. I have done treatment plans and such in session, but that is with 40+ clients full-time and still provided effective treatment. However, I do see therapy becoming more inflexible everywhere. I cover video supervision for other MH units when they need supervisors since the pandemic and a lot what I see is formulaic. The art of developing a therapeutic relationship seems to be lost. A lot of scripted EBPs in the VA.

 

[futureapppsy2]

I recently had a colleague tell me that she had been in therapy with midlevel providers on and off for "procrastination issues" for decades but that she had never been given a diagnosis and that their "treatment" had been minimally effective at best so that she had just concluded that this was some weird, unique problem that could never be diagnosed or treated. She described her symptoms, and they were pretty much textbook inattentive ADHD. I asked her if she had ever been assessed for that, and she said that only one of the multiple midlevel therapists she'd seen over decades had even mentioned it and that that one had simply told her that she couldn't have it as she wasn't hyperactive or a young boy. I strongly recommended to her that she get an actual comprehensive assessment from a doctoral-level provider, and when she did, she was diagnosed with and given appropriate treatment for ADHD. It was so incredibly textbook that I'm genuinely baffled and embarrassed that multiple therapists completely missed it.

 

[Sanman]

I recently had a colleague tell me that she had been in therapy with midlevel providers on and off for "procrastination issues" for decades but that she had never been given a diagnosis and that their "treatment" had been minimally effective at best so that she had just concluded that this was some weird, unique problem that could never be diagnosed or treated. She described her symptoms, and they were pretty much textbook inattentive ADHD. I asked her if she had ever been assessed for that, and she said that only one of the multiple midlevel therapists she'd seen over decades had even mentioned it and that that one had simply told her that she couldn't have it as she wasn't hyperactive or a young boy. I strongly recommended to her that she get an actual comprehensive assessment from a doctoral-level provider, and when she did, she was diagnosed with and given appropriate treatment for ADHD. It was so incredibly textbook that I'm genuinely baffled and embarrassed that multiple therapists completely missed it.

Why so baffled? That sounds like a fairly typical experience from what I have seen. I have run across a lot of poorly diagnosed patients in my lifetime, but there is no money in accurate diagnosis so what do you expect.

 

[futureapppsy2]

Why so baffled? That sounds like a fairly typical experience from what I have seen. I have run across a lot of poorly diagnosed patients in my lifetime, but there is no money in accurate diagnosis so what do you expect.

I guess less "baffled" and more "annoyed by the evident crappiness that goes unquestioned and unchecked. Even my colleague was like "well, expecting people to do their jobs is a big ask so I couldn't have expected better" while simultaneously telling me that my accurate "diagnosis" was "life-changing." I mean, it was so incredibly textbook of a symptom description, too.

 

[erg923]

It was so incredibly textbook that I'm genuinely baffled and embarrassed that multiple therapists completely missed it.

I'm not baffled. It is a shame, though. Clinically inattentive, sloppy, or just not bothering to attempt best practice is rampant in the MH system. This isn't to say that everyone needs more, more, more, or giant testing batteries either.

IME: It's due to large caseloads that are managed by largely masters-level providers, poor training and clinical myths and misinformation that abound, and pressure to get billable units of...something. In rural areas, there is probably a legitimate lack of availability of psychiatrists and psychologists to even attempt to work people (especially kids) up. Or at least ones that want to actually spend time and do best practice of anything. I just recently had to speak with several providers who were diagnosing DMDD and ADHD is 3 year olds, and another set of agencies who where regularly requesting 5 hours a day 5 days a week of day treatment services (essentially PHP) for 4, 5, and 6 year olds....many of whom had DMDD and/or Conduct Disorder diagnoses. The absurdity is extreme on soooo many levels. I mean, most adults MH patient can't really attend/engage to that much treatment....much less a 4 or 5 year old. lol.

 

[Sanman]

I'm not. Clinically inattentive, sloppy, or just not bothering to attempt best practice is rampant in the MH system. This isn't to say that everyone needs more, more, more, or giant testing batteries either.

IME: Its large caseloads that are managed by largely masters level providers, poor training and clinical myths and misinformation that abound, and pressure to get billable units of...something. In rural areas, there is probably a legitimate lack of availability of psychiatrists and psychologists to even attempt to work people (especially kids) up. Or at least ones that want to actually spend time and do best practice of anything. I just recently had to speak with several providers who were diagnosing DMDD and ADHD is 3 year olds, and another set of agencies who where regularly requesting 5 hours a day 5 days a week of day treatment services (essentially PHP) for 4 and 5 year olds....many of whom had DMDD and/or Conduct disorder diagnoses.

Agreed, I also think that this is a byproduct of decreasing reimbursements, a push for cheap labor, and a lack of incentives in the billing system to do good work. Even when you know the correct diagnosis, there is pressure to bill it as a known quantity that will get reimbursed.

 

[erg923]

Agreed, I also think that this is a byproduct of decreasing reimbursements, a push for cheap labor, and a lack of incentives in the billing system to do good work. Even when you know the correct diagnosis, there is pressure to bill it as a known quantity that will get reimbursed.

Additional 90791s can be billed when there is a substantial change in condition that is focus of treatment, non response to treatment, not to mention twice per year on the most heavily managed plan that I have seen. There are also complexity and add-on codes. There is really no excuse for: "I (or somebody) has been treating this person for a year and have not bothered to do a SCID or SADS or insert other structure psychiatric evaluation here."

And, for goodness sake...how hard it it to give a Connors, WURS, MDQ, or insert other investigational self or collateral report here? No excuse for that either. Not recognizing textbook ADHD to at least investigate it a little is clinical incompetence at a certain point?

 

[Sanman]

Additional 90791s can be billed when there is substantial change in condition, non response to treatment, not to mention twice per year on the most medically managed plan that I have seen. There are also complexity and add-on codes. There is really no excuse for: "I (or somebody) has been treating this person for a year and have not bothered to do a SCID or SADS or insert other structure psychiatric evaluation here.

This is a cart and horse issue, people that can't diagnose properly also have no idea how to properly use a 90791 or most add on codes either. The number of post-docs and licensed clinicians (both private and VA) that I have had to educate of the time intervals for 90832, 90834, 90837 is amazing. Let alone more complex ways to bill and code

 

[erg923]

This is a cart and horse issue, people that can't diagnose properly also have no idea how to properly use a 90791 or most add on codes either. The number of post-docs and licensed clinicians (both private and VA) that I have had to educate of the time intervals for 90832, 90834, 90837 is amazing. Let alone more complex ways to bill and code

And I would argue that unless you are practicum student, not knowing this is laziness or incompetence. You (not you personally) have chosen to work in healthcare. The least you can do is try to see what you can do. Its not hard to look this stuff up.

 

[cara susanna]

Even in places where there is psychological assessment available, I've seen it over-utilized when the referring clinician could figure it out on their own. Sometimes I feel like some people use us as a diagnostic service.

 

[Sanman]

And I would argue that unless you are practicum student, not knowing this is laziness or incompetence. You (not you personally) have chosen to work in healthcare. The least you do is try to see what you can do. Its not hard to look it up.

Oh completely agreed. Not to mention that there are many times in training where best practices are stressed in clinical skills (which is good), but few times where anyone to wants to train others to stop committing fraud (which is not just nice, but a crime unlike crappy diagnosis).

 

[erg923]

Even in places where there is psychological assessment available, I've seen it over-utilized when the referring clinician could figure it out on their own. Sometimes I feel like some people use us as a diagnostic service.

IME: Some (many?) psychiatrists and psychologists seem scared or ignorant to diagnose ADHD. This is baffling to me cause it is such a ubiquitous dx and really isn't all that hard to rule-out if you just...try. It makes me wonder what they teach about this disorder in psychiatric residency programs? Same with MDD vs Bipolar disorder? That has got to be bread and butter stuff for a psychiatrist, I mean, come on? Have they had manic episode or not? Spend some time. Get an MDQ...or something. There is such as thing as too much data and too much input/opinion in order to be helpful/render treatment.

 

[Sanman]

IME: Some (many?) psychiatrists seem scared or ignorant to diagnose ADHD. This is baffling to me cause it is such a ubiquitous dx and really isn't all that hard to rule-out if you just...try. It makes me wonder what they teach about this disorder is psychiatric residency programs? Same with MDD vs Bipolar disorder? That has got to be bread and butter stuff for a psychiatrist, I mean, come on? Have they had manic episode or not? Spend some time. Get an MDQ...or something. There is such as thing as too much data and too much input/opinion in order to be helpful/render treatment.

Mulling it over, I feel like the heart of the problem is this (for physicians or psychologists); they send us to school for the better part of a decade and then put us all in a system where thinking is disincentivized and poorly (or just plain not) compensated.

 

[futureapppsy2]

Even in places where there is psychological assessment available, I've seen it over-utilized when the referring clinician could figure it out on their own. Sometimes I feel like some people use us as a diagnostic service.

Eh, tbh, I'd rather have physicians refer for assessment than do a crappy, half-assed job of it. I've had to explain to multiple families that their child did not in fact have autism/ASD (after a comprehensive assessment) even if their pediatrician had told them that on the basis of a five-minute observation and the GARS (which is an absolutely terrible instrument). Inappropriate referrals for neuropsych assessment on the other hand... 100% feel you there.

 

[cara susanna]

Eh, tbh, I'd rather have physicians refer for assessment than do a crappy, half-assed job of it. I've had to explain to multiple families that their child did not in fact have autism/ASD (after a comprehensive assessment) even if their pediatrician had told them that on the basis of a five-minute observation and the GARS (which is an absolutely terrible instrument). Inappropriate referrals for neuropsych assessment on the other hand... 100% feel you there.

I agree, but our referrals are from MH providers who are trained in psychological diagnosis. I've even had referrals for diagnostic clarification where the patient had been seen for fewer than four visits. I also agree with erg, some of the stuff I'm asked to assess for doesn't need psych testing. More than half of the diagnostic questions I'm asked could be resolved with a good chart review and clinical interview*. Don't even get me started on ADHD testing.

And I'm in the VA so a lot of our pts invalidate the fancy objective tests. What then?

*I am aware that part of the issue is I am given time for this when I do testing, whereas providers who do not do testing are not.

 

[AcronymAllergy]

IME: Some (many?) psychiatrists seem scared or ignorant to diagnose ADHD. This is baffling to me cause it is such a ubiquitous dx and really isn't all that hard to rule-out if you just...try. It makes me wonder what they teach about this disorder is psychiatric residency programs? Same with MDD vs Bipolar disorder? That has got to be bread and butter stuff for a psychiatrist, I mean, come on? Have they had manic episode or not? Spend some time. Get an MDQ...or something. There is such as thing as too much data and too much input/opinion in order to be helpful/render treatment.

Agreed, but trust me (as I'm sure you know from your experience), it's not just psychiatrists and social workers. I routinely see psychologists punt on this as well, and then want to get a neuropsych on the (adult) patient. I literally just recently got off the phone because the referral source couldn't find a psychologist willing to perform the assessment (i.e., a clinical interview).

It seems to be a bimodal distribution across providers: a number of folks who are overly-generous with the diagnosis, a number of folks who never want to evaluate for it, and a limited number of people in-between providing some semblance of a scientifically-grounded/evidence-based assessment and diagnosis. Anecdotally, the first group seems to be more often in private practice and the second more often in VA. Where I am, it's actually our psychiatrists who seem most comfortable making the diagnosis.

Edit: And I agree with cara that it may often relate to time allotted (or the lack thereof), and getting tired of volunteering for extra duties for which one receives neither additional compensation or recognition.

 

[erg923]

I agree, but our referrals are from MH providers who are trained in psychological diagnosis. I've even had referrals for diagnostic clarification where the patient had been seen for fewer than four visits. I also agree with erg, some of the stuff I'm asked to assess for doesn't need psych testing. More than half of the diagnostic questions I'm asked could be resolved with a good chart review and clinical interview*. Don't even get me started on ADHD testing.

And I'm in the VA so a lot of our pts invalidate the fancy objective tests. What then?

*I am aware that part of the issue is I am given time for this when I do testing, whereas providers who do not do testing are not.

The most reliable and valid way to diagnose most psychiatric conditions is by using a structured clinical interview (as opposed to one's own idiosyncratic clinical interviewer session...which is prone to lack of follow-up, distraction, laziness, poor question wording, lack of adherence to DSM criteria, and not attending to the "not otherwise accounted for by" clause of DSM), observation during session, and collateral information that is then supplemented by some normative/rating scale data. And yes, this might take more than 60 minutes. Sorry. This is not new, surprising, or controversial to anyone who is even the least bit up-to-date on the matter. Many psychologists, for whatever reason, seem not to understand this, even though it is well spelled out in the literature. The "test boundness" of some psychologists is, frankly, embarrassing.

Additional information is needed for some things and situations/cases...of course.

 

[erg923]

It seems to be a bimodal distribution across providers: a number of folks who are overly-generous with the diagnosis, a number of folks who never want to evaluate for it, and a limited number of people in-between providing some semblance of a scientifically-grounded/evidence-based assessment and diagnosis. Anecdotally, the first group seems to be more often in private practice and the second more often in VA. Where I am, it's actually our psychiatrists who seem most comfortable making the diagnosis.

I am often flummoxed by by this. The DSM exists as a clinically flexible set of criteria, yet psychologists want to simultaneously use it concretely and without critical thought to its caveats for certain disorders...but then also want to do all kinds of stuff/testing (attention tests, memory tests, EF tests) to prove/show that things that aren't part of the disorders criteria prove the patient meets criteria for ADHD? This does not make sense to me?

 

[beginner2011]

The most reliable and valid way to diagnose most psychiatric conditions is by using a structured clinical interview (as opposed to one's own idiosyncratic clinical interviewer session...which is prone to lack of follow-up, distraction, laziness, poor question wording, lack of adherence to DSM criteria, and not attending to the "not otherwise accounted for by" clause of DSM), observation during session, and collateral information that is then supplemented by some normative/rating scale data. And yes, this might take more than 60 minutes. Sorry. This is not new, surprising, or controversial to anyone who is even the least bit up-to-date on the matter. Many psychologists, for whatever reason, seem not to understand this, even though it is well spelled out in the literature. The "test boundness" of some psychologists is, frankly, embarrassing.

Additional information is needed for some things and situations/cases...of course.

A little off topic, but I think Tolin's DIAMOND is a fantastic resource that is also FREE, while most structured instruments are not (e.g., SCID and MINI). Diamond Training Agreement - Hartford Hospital

 

[PsyDr]

I am often flummoxed by by this. The DSM exists as a clinically flexible set of criteria, yet psychologists want to simultaneously use it concretely and without critical thought to its caveats for certain disorders...but then also want to do all kinds of stuff/testing (attention tests, memory tests, EF tests) to prove/show that things that aren't part of the disorders criteria prove the patient meets criteria for ADHD? This does not make sense to me?

Then you’ve never had a middle aged person, with no supporting history, threatening
you while demanding stimulants.

 

[erg923]

Then you’ve never had a middle aged person, with no supporting history, threatening
you while demanding stimulants.

No. And threatining? Would call local law enforcement. No procedures or test would be done if harm was threatened to me.

 

[PsyDr]

No. And threatining? Would call local law enforcement. No procedures or test would be done if harm was threatened to me.

No kidding.

Now imagine if it wasn’t threatening. Imagine a middle aged patient strolls in, rattles off the adhd criteria in a way that shows they’ve memorized it. What are you gonna do? Tell them that even though they reported the right symptoms, you think they’re lying? And would you say they’re lying without proof?

My point was that neuropsych testing is often ordered because the patient has clearly after something, and the prescriber needs a way to call shenanigans without creating direct conflict.

A structured interview won’t do that.

 

[erg923]

No kidding.

Now imagine if it wasn’t threatening. Imagine a middle aged patient strolls in, rattles off the adhd criteria in a way that shows they’ve memorized it. What are you gonna do? Tell them that even though they reported the right symptoms, you think they’re lying? And would you say they’re lying without proof?

Doing a battery of testing that includes SVT for every self-reported ADHD case would of course be cost-prohibitive for the health system.

Do we not have clinical judgment? And does this not (except maybe in in the VA system or something similar) include me saying: "No... based upon my clinical training, clinical judgement and understanding of this disorder... I think you are mistaken (or full of bullhonky), Sir." Based upon your reported clinical and developmental history, I cannot agree that this is the best or most accurate diagnosis for you at this this time. I can do X, Y, Z for you at this time. If that is not acceptable to you, you may be better helped by these other providers/resources.

I've done this, in a more nuanced fashion certainly... many times.

 

[Sanman]

I am often flummoxed by by this. The DSM exists as a clinically flexible set of criteria, yet psychologists want to simultaneously use it concretely and without critical thought to its caveats for certain disorders...but then also want to do all kinds of stuff/testing (attention tests, memory tests, EF tests) to prove/show that things that aren't part of the disorders criteria prove the patient meets criteria for ADHD? This does not make sense to me?

Why flummoxed? Those that make money from diagnosing will diagnose. Those that have free access to tests will test. Good clinical judgment has little to do with it. Though, I do hope to use the term "bullhonky" more often in my life.

 

[erg923]

Though, I do hope to use the term "bullhonky" more often in my life.

You would prefer "poppycock?"

I am also prone to the term "Hokum."

 

[Sanman]

You would prefer "poppycock?"

I am also prone to the term "Hokum."

Of the three bullhonky is definitely my favorite. Hokum and poppycock are fun too though.

 

[tr]

IME: Some (many?) psychiatrists and psychologists seem scared or ignorant to diagnose ADHD. This is baffling to me cause it is such a ubiquitous dx and really isn't all that hard to rule-out if you just...try. It makes me wonder what they teach about this disorder in psychiatric residency programs? Same with MDD vs Bipolar disorder? That has got to be bread and butter stuff for a psychiatrist, I mean, come on? Have they had manic episode or not? Spend some time. Get an MDQ...or something. There is such as thing as too much data and too much input/opinion in order to be helpful/render treatment.

I believe the urge to send people for neuropsych testing to assist with ADHD diagnosis has to do with people wanting to have some corroborating evidence for the diagnosis before handing out stimulants. If the optimal treatment weren't a highly abusable Schedule II I doubt you'd see a tenth of the testing referrals you're seeing now.

I don't know what's up with people referring for neuropsych testing to differentiate unipolar from bipolar (I've never heard of this) but I take exception to the claim that this is a simple diagnostic call. Bipolar disorder is a wide spectrum of disease and a history of subtle hypomanias can be easy to miss even on careful interview, but then come back to bite you with a raging manic switch from an unopposed antidepressant. Manic switching doesn't care if you missed meeting the DSM criteria by one day or a couple of symptoms either. It's just not cut and dried.

 

[cara susanna]

I believe the urge to send people for neuropsych testing to assist with ADHD diagnosis has to do with people wanting to have some corroborating evidence for the diagnosis before handing out stimulants. If the optimal treatment weren't a highly abusable Schedule II I doubt you'd see a tenth of the testing referrals you're seeing now.

I don't know what's up with people referring for neuropsych testing to differentiate unipolar from bipolar (I've never heard of this) but I take exception to the claim that this is a simple diagnostic call. Bipolar disorder is a wide spectrum of disease and a history of subtle hypomanias can be easy to miss even on careful interview, but then come back to bite you with a raging manic switch from an unopposed antidepressant. Manic switching doesn't care if you missed meeting the DSM criteria by one day or a couple of symptoms either. It's just not cut and dried.

The thing is the "evidence" for ADHD isn't really evidence. At least according to research. You may as well be diagnosing them based on their Zodiac sign. If anything, it's worse because the neuropsych testing gives a feeling of false expertise. We've had people in our clinics diagnosed with ADHD by us (psychological, non-neuropsychological testing) and then STILL referred for neuropsych testing for ADHD because the psychiatrist thought they needed npsych.

 

[futureapppsy2]

The thing is the "evidence" for ADHD isn't really evidence. At least according to research. You may as well be diagnosing them based on their Zodiac sign. If anything, it's worse because the neuropsych testing gives a feeling of false expertise. We've had people in our clinics diagnosed with ADHD by us (psychological, non-neuropsychological testing) and then STILL referred for neuropsych testing for ADHD because the psychiatrist thought they needed npsych.

It's a non-evidence-based waste of time and money that does not aid in accurate diagnosis.

https://www.tandfonline.com/doi/abs/10.1037/mil0000138

 

[DynamicDidactic]

It's a non-evidence-based waste of time and money that does not aid in accurate diagnosis.

https://www.tandfonline.com/doi/abs/10.1037/mil0000138

Can you elaborate? The link is only to the abstract (can't get full article at the moment). Are you saying that the evidence indicates there is no incremental validity from additional testing past a standardized interview?

 

[PsyDr]

I believe the urge to send people for neuropsych testing to assist with ADHD diagnosis has to do with people wanting to have some corroborating evidence for the diagnosis before handing out stimulants. If the optimal treatment weren't a highly abusable Schedule II I doubt you'd see a tenth of the testing referrals you're seeing now.

I don't know what's up with people referring for neuropsych testing to differentiate unipolar from bipolar (I've never heard of this) but I take exception to the claim that this is a simple diagnostic call. Bipolar disorder is a wide spectrum of disease and a history of subtle hypomanias can be easy to miss even on careful interview, but then come back to bite you with a raging manic switch from an unopposed antidepressant. Manic switching doesn't care if you missed meeting the DSM criteria by one day or a couple of symptoms either. It's just not cut and dried.

erg is also missing that the DSM highly suggests the use of collateral information. The DSM also specifically indicates that self report about the past is highly inaccurate in adhd adult samples.

 

[tr]

It's a non-evidence-based waste of time and money that does not aid in accurate diagnosis.

https://www.tandfonline.com/doi/abs/10.1037/mil0000138

I know that, and I don't routinely send people for neuropsych testing for AD/HD dx. (I had a period of time in the past where I was more prone to do this, but I realized it was a really expensive and time-consuming way of essentially signaling to the patient that I was not an automatic amphetamine dispenser. As pointed out by @PsyDr, requiring collateral information is a better way to achieve both the diagnostic and the signaling objectives. )

I was just pointing out that the motivation for requesting it is probably not related to an actual difficulty with making the dx.

 

[AcronymAllergy]

erg is also missing that the DSM highly suggests the use of collateral information. The DSM also specifically indicates that self report about the past is highly inaccurate in adhd adult samples.

Collateral report can be very helpful to borderline-essential, yep. Although I want to say Barkley and a few others have evidence suggesting at least a moderate degree of accuracy of current and retrospective self-report in adults with current and/or h/o ADHD. Minus the whole secondary gain thing. And Barkley does happen to publish/sell a handful of self-report measures.

 

[AcronymAllergy]

I know that, and I don't routinely send people for neuropsych testing for AD/HD dx. (I had a period of time in the past where I was more prone to do this, but I realized it was a really expensive and time-consuming way of essentially signaling to the patient that I was not an automatic amphetamine dispenser. As pointed out by @PsyDr, requiring collateral information is a better way to achieve both the diagnostic and the signaling objectives. )

I was just pointing out that the motivation for requesting it is probably not related to an actual difficulty with making the dx.

Anecdotally, this (i.e., obtaining some form of objective evidence) has far and away been the #1 reason psychiatrists have said they referred people to me for a neuropsych for ADHD. Even when I let them know about the research on neuropsych testing and ADHD, they still often want it done. Can't say I blame them. I wish we had better tests/support for it.

 

[cara susanna]

I know that, and I don't routinely send people for neuropsych testing for AD/HD dx. (I had a period of time in the past where I was more prone to do this, but I realized it was a really expensive and time-consuming way of essentially signaling to the patient that I was not an automatic amphetamine dispenser. As pointed out by @PsyDr, requiring collateral information is a better way to achieve both the diagnostic and the signaling objectives. )

I was just pointing out that the motivation for requesting it is probably not related to an actual difficulty with making the dx.

I get that. At the same time there HAS to be a better way of putting up barriers or making that signal without making a patient engage in something that is not actually clinically indicated. And without wasting the psychologist's time as well.

 

[WisNeuro]

I get that. At the same time there HAS to be a better way of putting up barriers or making that signal without making a patient engage in something that is not actually clinically indicated. And without wasting the psychologist's time as well.

Well, it isn't wasting my time when I simply refuse to take these referrals

 

[cara susanna]

Well, it isn't wasting my time when I simply refuse to take these referrals

If only I had that power

 

[WisNeuro]

If only I had that power

Well, you do. You just might have different consequences than I do.

 

[R. Matey]

Can you elaborate? The link is only to the abstract (can't get full article at the moment). Are you saying that the evidence indicates there is no incremental validity from additional testing past a standardized interview?

I'm going to drop this in the discussion. I would hope no one here is really saying that cognitive tests for ADHD are complete malarkey for all patients everywhere all of the time. For instance, college students may need testing to obtain disability accommodations.

https://www.tandfonline.com/doi/full/10.1080/13854046.2019.1696409

 

[WisNeuro]

I'm going to drop this in the discussion. I would hope no one here is really saying that cognitive tests for ADHD are complete malarkey for all patients everywhere all of the time. For instance, college students may need testing to obtain disability accommodations.

https://www.tandfonline.com/doi/full/10.1080/13854046.2019.1696409

The issue with this piece is that nearly all of the neuropsych studies looked at ADHD vs. controls or mood disorders as the comparison groups. Which in itself is somewhat problematic in that ADHD and mood disorders are commonly comorbid. Furthermore, this usually isn't what we have to deal with in the real world as we have patients coming in with SUD, TBI, possible dementia, wanting an "ADHD eval." They pretty clearly state that adding cognitive testing can improve specificity in differentiating ADHD from mood, though that increase in specificity is pretty minimal. Another issue is that the original studies of the QBT used itself as a gold standard, kind of poisoning that well. I still think testing makes sense in school type settings when we need to look at possible LD or malingering, but the individual predictive power in most settings is still substandard for neuropsych tests in this population.

 

[R. Matey]

The issue with this piece is that nearly all of the neuropsych studies looked at ADHD vs. controls or mood disorders as the comparison groups. Which in itself is somewhat problematic in that ADHD and mood disorders are commonly comorbid. Furthermore, this usually isn't what we have to deal with in the real world as we have patients coming in with SUD, TBI, possible dementia, wanting an "ADHD eval." They pretty clearly state that adding cognitive testing can improve specificity in differentiating ADHD from mood, though that increase in specificity is pretty minimal. Another issue is that the original studies of the QBT used itself as a gold standard, kind of poisoning that well. I still think testing makes sense in school type settings when we need to look at possible LD or malingering, but the individual predictive power in most settings is still substandard for neuropsych tests in this population.

I’ll take your word for it because you’re clearly more of an expert in this area than I am, but I am curious what a standard body of evidence would look like. I’ve used a few of these tests in training to diagnosis ADHD in the past and it makes all of the difference.


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[WisNeuro]

I’ll take your word for it because you’re clearly more of an expert in this area than I am, but I am curious what a standard body of evidence would look like. I’ve used a few of these tests in training to diagnosis ADHD in the past and it makes all of the difference.


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How, specifically? Also, what is the base rates of those differences in general populations, populations with mood disorders, etc? We have to be careful not to fall into the trap of confirmatory biases. Far too often I'll see people over-interpreting differences on the WAIS to justify ADHD or other diagnoses. For example, noting a difference in PSI from another index or general ability, when in truth, that level of discrepancy is seen in roughly 25% of healthy controls.

 

[WisNeuro]

Also, we're not exactly picking on ADHD alone here, Sens/Spec.PPP/NPP could be improved in a lot of areas/diagnoses, this just happens to be a particularly hot button topic in neuropsych with regards to testing.

 

[R. Matey]

How, specifically? Also, what is the base rates of those differences in general populations, populations with mood disorders, etc? We have to be careful not to fall into the trap of confirmatory biases. Far too often I'll see people over-interpreting differences on the WAIS to justify ADHD or other diagnoses. For example, noting a difference in PSI from another index or general ability, when in truth, that level of discrepancy is seen in roughly 25% of healthy controls.

I don't remember off hand. It's been a couple of years and I no longer have access to my reports (which were approved by my supervisor from a training site you've endorsed in other threads). I think if I was treating the cognitive testing as a sole indicator, you'd have something to worry about.

 

[erg923]

I’ll take your word for it because you’re clearly more of an expert in this area than I am, but I am curious what a standard body of evidence would look like. I’ve used a few of these tests in training to diagnosis ADHD in the past and it makes all of the difference.


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Whats "all the difference???"

Although it is possible for researchers to learn quite a bit about ADHD from small-to-modest mean differences in test performance, attention tests do not improve individual diagnostic accuracy because problems with attention (or any other cognitive function) are not part of the DSM criteria. And there is a reason for that.

Also, you need to keep in mind your phrase... "in training.' Its common for supervisors not to really care to much about what is needed, efficient, discriminatory, actually translatable to a treatment plan, etc when training grad students. They arent billing for it and you need to learn how to give instruments anyway. So, why not? I dont really agree with this philosophy of training, but its the predominate one out there.

 

[WisNeuro]

I don't remember off hand. It's been a couple of years and I no longer have access to my reports (which were approved by my supervisor from a training site you've endorsed in other threads). I think if I was treating the cognitive testing as a sole indicator, you'd have something to worry about.

I'm not saying that there aren't neuropsychs using tests to diagnose ADHD, I'm just saying that they are not using a solid evidence base to do so in some situations. Unfortunately, we still have a lot of neuropsych clinical myths that persist. One of the reasons one of my first didactics goes over some of these clinical lore issues and explores the evidence base behind them.

 

[R. Matey]

I'm not saying that there aren't neuropsychs using tests to diagnose ADHD, I'm just saying that they are not using a solid evidence base to do so in some situations. Unfortunately, we still have a lot of neuropsych clinical myths that persist. One of the reasons one of my first didactics goes over some of these clinical lore issues and explores the evidence base behind them.

I agree with you there though I've seen the clinical mythos more at play in psychotherapy. It's sad to see that it also extends to testing.