Psychological assessment of veterans 9780199985739, 0199985731

Table of contents :
Pt. 1. Foundations. History of the Psychological Assessment of Veterans / Rodney R. Baker --
pt. 2. Contexts. Psychological assessment of veterans in outpatient mental health settings / Nathaniel W. Nelson, Carly R. Anderson, James B. Hoelzle, and Paul A. Arbisi --
Psychological assessment of veterans in long-term care / Michael L. Drexler --
Psychological assessment of veterans in primary care-mental health integration contexts / Lisa K. Kearney, Laura O. Wray, Katherine M. Dollar, Paul R. King, and Christina L. Vair --
Psychological assessment of veterans in home based primary care / B. Heath Gordon and Michele J. Karel --
Assessment via telemental health technology / Matthew S. Yoder and Travis H. Turner --
pt. 3. Disorders. Psychological assessment of veterans with substance use disorders / Dominick DePhilippis, Jessica D. Goodman, and James R. McKay --
Schizophrenia spectrum and other psychotic disorders: general considerations / Daniel N. Allen and Gerald Goldstein --
Schizophrenia spectrum and other psychotic disorders: test measures and procedures / Daniel N. Allen and Gerald Goldstein --
Assessment of mood disorders and suicidal thoughts and behavior in veterans / Beeta Y. Homaifar, Jennifer Olson-Madden, Bridget Matarazzo, and Lisa A. Brenner --
Psychological assessment of veterans with PTSD and other anxiety disorders / Christy A. Blevins, Daniel J. Lee, and Frank W. Weathers --
Beyond diagnosis: assessment of ADHD among military veterans / Mark A. Sandberg and Susan R. Green --
Assessment of psychological symptoms in persons with dementia / Sandra Zinn --
The psychological assessment of veterans with pain and pain-related disorders / John D. Otis, Andrea Levine, and Diana M. Higgins --
The psychological assessment of veterans with history of polytrauma / John Linck and Jared Benge --
pt. 4. Special considerations. Assessment of symptom and performance validity in veterans / Shane S. Bush --
Psychosocial assessment of homeless veterans / Anne S. Klee and Howard R. Steinberg --
Health-related quality of life among veterans / S. Marc Testa --
Ethical, legal, and professional considerations in the psychological assessment of veterans / Shane S. Bush.

Citation preview

Psychological Assessment of Veterans

Psychological Assessment of Veterans EDITED BY SHANE S. BUSH

1

1 Oxford University Press is a department of the University of Oxford. It furthers the University’s objective of excellence in research, scholarship, and education by publishing worldwide. Oxford New York Auckland  Cape Town  Dar es Salaam  Hong Kong  Karachi Kuala Lumpur Madrid Melbourne Mexico City Nairobi New Delhi Shanghai Taipei Toronto With offices in Argentina Austria Brazil Chile Czech Republic France Greece Guatemala Hungary Italy Japan Poland Portugal Singapore South Korea Switzerland Thailand Turkey Ukraine Vietnam Oxford is a registered trademark of Oxford University Press in the UK and certain other countries. Published in the United States of America by Oxford University Press 198 Madison Avenue, New York, NY 10016

© Oxford University Press 2014 All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, without the prior permission in writing of Oxford University Press, or as expressly permitted by law, by license, or under terms agreed with the appropriate reproduction rights organization. Inquiries concerning reproduction outside the scope of the above should be sent to the Rights Department, Oxford University Press, at the address above. You must not circulate this work in any other form and you must impose this same condition on any acquirer. Library of Congress Cataloging-in-Publication Data Psychological assessment of veterans / edited by Shane S. Bush.   pages cm Includes bibliographical references and index. ISBN 978–0–19–998572–2 1.  Veterans—Mental health—United States.  2.  Veterans—Mental health services— United States. 3.  Veterans—Psychology—United States. 4.  Psychodiagnostics.  5.  Personality assessment.  6.  Psychological tests.  7.  United States. Veterans Administration.  I.  Bush, Shane S., 1965– UH629.3.P79 2014 616.89′07508697—dc23 2014011120 Much of the information covered in this book relates to psychological services provided within the Department of Veterans Affairs and other departments of the US Government. However, unless otherwise stated, the opinions expressed in this book are those of the individual authors and do not represent the official position of the Department of Veterans Affairs, Department of Defense, US Government, or any specific VA facility or program.

9 8 7 6 5 4 3 2 1 Printed in the United States of America on acid-free paper

In loving memory of SJO and JRB, both retired Air Force mustang officers, veterans of foreign wars, and my grandfathers.

CONTENTS

Foreword  xi Patrick H. DeLeon and Paul C. Lewis Preface  xvii Shane S. Bush List of Contributors  xxi PART ONE  Foundations  1. History of the Psychological Assessment of Veterans  3 Rodney R. Baker PART TWO  Contexts  2. Psychological Assessment of Veterans in Outpatient Mental Health Settings  17 Nathaniel W. Nelson, Carly R. Anderson, James B. Hoelzle, and Paul A. Arbisi 3. Psychological Assessment of Veterans in Long-Term Care  51 Michael L. Drexler 4. Psychological Assessment of Veterans in Primary Care–Mental Health Integration Contexts  88 Lisa K. Kearney, Laura O. Wray, Katherine M. Dollar, Paul R. King, and Christina L. Vair 5. Psychological Assessment of Veterans in Home Based Primary Care  127 B. Heath Gordon and Michele J. Karel 6. Assessment via Telemental Health Technology  159 Matthew S. Yoder and Travis H. Turner

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PART THREE  Disorders  7. Psychological Assessment of Veterans with Substance Use Disorders  177 Dominick DePhilippis, Jessica D. Goodman, and James R. McKay 8. Schizophrenia Spectrum and Other Psychotic Disorders: General Considerations  215 Daniel N. Allen and Gerald Goldstein 9. Schizophrenia Spectrum and Other Psychotic Disorders: Test Measures and Procedures  246 Daniel N. Allen and Gerald Goldstein 10. Assessment of Mood Disorders and Suicidal Thoughts and Behavior in Veterans  279 Beeta Y. Homaifar, Jennifer Olson-Madden, Bridget Matarazzo, and Lisa A. Brenner 11. Psychological Assessment of Veterans with PTSD and Other Anxiety Disorders  297 Christy A. Blevins, Daniel J. Lee, and Frank W. Weathers 12. Beyond Diagnosis: Assessment of ADHD among Military Veterans  324 Mark A. Sandberg and Susan R. Green 13. Assessment of Psychological Symptoms in Persons with Dementia  343 Sandra Zinn 14. The Psychological Assessment of Veterans with Pain and Pain-Related Disorders  382 John D. Otis, Andrea Levine, and Diana M. Higgins 15. The Psychological Assessment of Veterans with History of Polytrauma  404 John Linck and Jared Benge PART FOUR  Special Considerations  16. Assessment of Symptom and Performance Validity in Veterans  433 Shane S. Bush 17. Psychosocial Assessment of Homeless Veterans  453 Anne S. Klee and Howard R. Steinberg

Contents

18. Health-Related Quality of Life among Veterans  483 S. Marc Testa 19. Ethical, Legal, and Professional Considerations in the Psychological Assessment of Veterans  494 Shane S. Bush Afterword  515 Bradley E. Karlin Index 521

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FOREWORD

An Important and Expanding Vision of Quality Care P at r i c k H . D e l e o n Uniformed Services University of the Health Sciences University of Hawaii Former President, American ­Psychological Association P au l C . L e w i s Colonel, US Army Uniformed services University of the Health sciences

It is gratifying to see this renewed interest in the importance of providing our nation, and particularly our veterans, with high-quality and truly comprehensive psychological assessments—assessments that are the key to ensuring appropriate stateof-the-art health care. As a discipline, psychology has historically prided itself on its expertise in “psychological testing.” If the psychologists of the 1930s and 1940s could have foreseen the communication and technological advances that would occur in the twenty-first century, they would have known that their exploratory efforts in defining this new empirical field would represent a priceless investment and would form the bedrock for today’s mature and expanding discipline. By systematically evaluating individual differences, utilizing statistical measurements, and determining the underlying questions, today’s psychologists are leading the discipline to exciting intellectual and clinical challenges unsurpassed by scientists in the more physical-oriented worlds. And, without question, the ultimate clinical benefits are reaped by the patients. HEALTH POLICY: TROUBLED PAST, ENCOURAGING FUTURE It was unfortunate, during the “managed care” days of Presidents Nixon and Clinton—with the dominant emphasis on bottom-line cost-containment—to witness a notable decrease in the clinical value attached to comprehensive assessments,

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especially within the behavioral and mental health environment. The expanded “carve out” for mental health reimbursement, along with the resurgence of academic and clinical silos (i.e., professional isolation), furthered this demise. Mental and behavioral healthcare was seen as fundamentally separate from physical healthcare. Senior practitioners seriously wondered if reasonable reimbursement levels for assessments would continue to exist in the future, while professional training programs placed dramatically less emphasis on assessment than in the past. The priority during this period was to train multitudes of practicing clinicians, not to develop sensitive diagnosticians. Fortunately, not all shared this view. The comprehensive and inclusive vision of a few farsighted psychologists would lead them to become the champions of the specialty of health psychology. “Health psychology is a generic field of psychology, with its own body of theory and knowledge. . . . Within health psychology a professional specialty is evolving” (Stone, 1983, p. 9). Change would ultimately occur, although perhaps more slowly than anticipated by our farsighted behavioral colleagues (Johnson, 2013). Other political and economic pressures were coming to bear during this same period. It was becoming increasingly clear that the nation’s healthcare costs were escalating at a socially unacceptable rate, while significant access and quality of care concerns were also becoming more evident. As we entered the twenty-first century, our nation was spending far more on healthcare than any other industrialized nation; and yet, the United States continued to lag behind in almost all health outcomes compared to similar industrialized nations (Commonwealth Fund, 2013). Accordingly, there were increasing calls, especially among clinicians, taxpayers, and health policy experts (in particular, those affiliated with the Institute of Medicine [IOM]) for significant and radical change to the status quo. This groundswell ultimately resulted in the enactment of President Obama’s landmark Patient Protection and Affordable Care Act (ACA) (P.L. 111–148). Its passage was a significant accomplishment even given that comprehensive healthcare reform had been a significant policy agenda for almost every American president, regardless of political affiliation, since Franklin D. Roosevelt. At the heart of the ACA is a refreshing emphasis on providing patient-centered, integrated, holistic, and evidenced-based care in a timely manner to all Americans. Evidence-based practice is the translation of current scientific knowledge into sound clinical practice, while remaining cognizant of the social and cultural ­context within which that care is rendered. By placing educated patients at the center of their own care, clinicians must understand that social and environmental factors will heavily influence what patients ultimately decide is best for their own individual healthcare situation. With this in mind, significant resources are to be made available to facilitate the nation’s transition of healthcare philosophy, such as capitalizing on the unrealized potential inherent in the exceptional advances occurring within the communications and technology fields (i.e., telehealth, electronic health records, and virtual consultations). Educated consumers and providers are expected to be able to explore and make informed decisions based on cross-diagnostic, cross-population, and cross-provider profiles. Both treatment and prevention interventions will be implemented and, just as important, systematically evaluated. Clinical effectiveness research is to be targeted toward determining what services and clinical procedures are most appropriate for which patient populations and under what conditions.

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Developing systems of care, such as Accountable Care Organizations and Medical Homes as proposed in the Accountable Care Act (ACA), are being encouraged in order to facilitate a comprehensive approach, rather than continuing to rely on traditional individualized fee-for-service models. In essence, the underlying health policy objective is to steadily move our nation’s healthcare system from responding to acute clinical illnesses to embracing broadly defined patient wellness that is driven by objective, evidence-based standards and protocols. This does not remove clinical judgment, but it does offer a method to systematically evaluate the care rendered. If President Obama’s vision is to be ultimately fulfilled, it will, without question, take significant time. It will also require a fundamental change in orientation by clinicians and by society overall. It is absolutely critical for the reimbursement system to be reprioritized to encourage the development of high-quality, state-of-the-art assessment capabilities that can measure objective outcomes, on both an individual and population basis. It is during this transition from problem-based care to patient-centered care that new key providers will emerge. While our nation continues to struggle with traditional health issues such as cancer and heart disease, or population concerns of obesity and childhood asthma, clinicians are beginning to recognize the utility of adopting a psychology of health instead of a paradigm of illness. The World Health Organization defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (WHO, Preamble, 1946). This holistic perspective of mind, body, and spirit has been formalized in the Military and Department of Veterans Affairs (VA) model titled “Total Force Fitness,” which recognizes health as more than merely the absence of illness. This paradigm shift requires that new measures of health must be developed. Traditional medicine is very adept at measuring illness with diagnostic and biological measurements. With health as the baseline marker, the traditional medical model is left trying to measure the opposite outcome, or the absence of illness. Measuring disease is well understood, but how is health measured? Normal diagnostic and biological measurements denote an absence of illness, but they do not necessarily denote health. Health psychologists and advanced practice nurses are uniquely positioned to fill this void with their in-depth training in data-oriented analytical skills and their appreciation of the important contribution of the psychosocial-economic-cultural gradient of quality care (Anderson & Anderson, 2003). Times are changing, and technology has become an integral part of healthcare today. Technology is involved in every part of a patient visit, from automated appointments and electronic medical records (EMRs) to diagnostic testing and computer-scored standardized testing. Technology by itself is neither positive nor negative, but rather the application of technology is the crux of the decision-making process. All new technology must be carefully scrutinized to determine if it will actually improve the quality of healthcare being delivered. There is a growing and substantial need for scientifically determining how the advances occurring in the computer and technology fields can be effectively utilized to provide quality assessments in a timely fashion. One advantage of technology is the ability to readily process information and provide relevant data to the clinician to make decisions. However, that data must be quickly available to the clinician within the short allotted appointment time, as well as providing the most up-to-date information upon which the clinician can base a diagnosis. With the advent of the electronic medical record,

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many quality patient indicators will likely come from this source to assist clinicians and researchers in developing new metrics to measure health. In this technological era, these metrics will undoubtedly be linked to a computer-based measurement, which will evolve into an indication of population health. It is important to appreciate that the individual patient may well be at risk of becoming lost in this methodology if the “bottom line” becomes the reimbursement imperative without paying adequate attention to “the individual life stories.” Accordingly, the importance of individual, specific, and unique assessments cannot be overstated. Quality health assessments must be conducted and recorded on each patient in order for a true picture to emerge. Psychologists, advanced practice nurses, and affiliated healthcare providers must not lose sight of this critical and ethical need for an individual perspective within population metrics. WARRIORS AND THEIR FAMILIES As the impressive range of the authors’ expertise in this text reflects, our nation and our veterans are undergoing unprecedented demographic changes—thus exponentially expanding the need for quantitative-based assessment tools. US Army Surgeon General Patricia Horoho, testifying before the House of Representatives Appropriations Committee, stated: “The reality is that after more than a decade of war, our Military and our Nation face a time of significant changes and challenges. Army medicine is impacted by both the National healthcare conversation and the direction of the Military Health System. . . . By moving from a disease model to a health model, we can impact health on a National level. The health of the military and the health of the Nation are not separate discussions. Our Nation’s Warriors come from our citizens” (2013, verbal testimony). The US Army Surgeon General presents two viewpoints, both of which are troubling. The US population is aging. In 2009 there were 39.6  million Americans 65  years or older, representing 12.9% of the population. By 2030 this figure is projected to reach 72.1 million, or 19% of the nation. Given the current healthcare needs of this demographic, this represents a significant burden on our current healthcare system. The nation also has a legal and moral obligation to care for our returning wounded warriors after a decade of armed conflict. Those fortunate to work within the VA have found that by the year 2013, the VA was serving approximately 49.3  million beneficiaries, or 15.5% of the nation’s population, with a budget of $147.5 billion. Today the VA operates the largest federal healthcare delivery system, with 152 hospitals, 107 domiciliary residential rehabilitation treatment programs, 133 nursing homes, 300 Vet Centers, 70 mobile Vet Centers, and 821 outpatient clinics, as well as historically being the largest employer of psychologists and advanced practice nurses. It is estimated that 6.5 million patients, possessing every conceivable diagnosis, are treated by the VA annually (Sen. Rpt., 2013). Whenever diagnosticians attempt to assess the strengths and deficits of particular clinical populations (i.e., wounded warriors, the elderly, or children), considerable attention must, as the authors demonstrate, be given to the importance of developing culturally sensitive evaluations. The long and rich history of VA affiliations with university-based medical centers provides unprecedented collaborative opportunities for generations of clinicians of all disciplines. And, as the

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range of topics addressed in this impressive text vividly illustrates, there continues to be boundless collaborative, integrated, and interdisciplinary training, research, and treatment challenges within the ever expanding VA healthcare system. The demographics of the all-volunteer military have dramatically changed, which brings new challenges. In the Vietnam War era, only 15% of active duty members were parents, and those typically were officers. Today, 47% of the military have children, with 14% being single parents. Mothers make up 16% of the active duty force. There are approximately 1.9 million military children, ranging in ages from newborn to 18 years old, 1.3+ million of whom are school age. Approximately 225,000 have a parent who is deployed, with more than 700,000 children having experienced the deployment of one or more parents since 2001. Nearly 40% of all military children are affected by deployment by the age of 5. Military children who are particularly impacted include those in dual military families (95,000), those in single-parent households (74,000), and those children who have special healthcare needs (102,000). Deployments and frequent moves have increased the rates of substantiated abuse and neglect. This abuse and neglect profile rises by 42% immediately after the military parent leaves for deployment and right after they return from overseas. Nearly 35% of military children are considered “high risk” for psychosocial morbidity, and nearly 20% are considered “at risk” for maltreatment (DeLeon & Shafer, 2013). We would suggest that a decade from now many of the pioneers contributing to this text will have assisted in moving the field forward, thereby making a lasting contribution to the health and well-being of our Nation. As public service colleagues, we should be especially proud of their vision, dedication, and compassion. The views expressed here are those of the authors and do not reflect the official policy or position of the Uniformed Services University of the Health Sciences, the Department of Defense, or the United States government. REFERENCES Anderson, N. B., & Anderson, P. E. (2003). Emotional longevity: What really determines how long you live. New York, NY: Viking. The Penguin Group. The Commonwealth Fund. (2013). Confronting costs:  Stabilizing U.S.  health spending while moving toward a high performance health care system. Retrieved October 26, 2013, from http://www.commonwealthfund.org/~/media/Files/Publications/ Fund%20Report/2013/Jan/1653_Commission_confronting_costs_web_FINAL.pdf DeLeon, P. H., & Shafer, M. (2013, March 13). Primary care and public health: A vision for the future. PsycCRITICS, 58(11) Article 5. Horoho, P.  D. (2013, April 24). Testimony before the US House of Representatives Committee on Appropriations, Subcommittee on Defense. Retrieved October 26, 2013. from http://appropriations.house.gov/uploadedfiles/hhrg-113-ap02-wstate-horohol20130424.pdf Johnson, S.  B. (2013). Increasing psychology’s role in health research and health care. American Psychologist, 68(5), 311–321. Military Construction and Veterans Affairs, and Related Agencies Appropriation Bill, 2014. (June 27, 2013). US Senate Report # 113–48. The Patient Protection and Affordable Care Act [ACA]. [P.L. 111-148]. (HR 3590). (March 23, 2010).

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Stone, G.  C. (Ed.) (1983). National working conference on education and training in health psychology [Special issue]. Health Psychology, 2(5). World Health Organization (WHO). (1946). Preamble to the Constitution of the World Health Organization. Retrieved October 26, 2013, from http://www.who.int/ governance/eb/who_constitution_en.pdf

PREFACE

The psychological assessment of veterans is many things, practiced in wide-ranging settings to address the varied clinical and administrative needs of diverse veteran populations. The diversity of veterans includes not only demographics and a broad spectrum of human experiences, it also encompasses different military experiences, from very brief periods in the military to lengthy careers, from relatively safe tours in comfortable environments to multiple combat deployments. Yet, all veterans, through their common experience of having served in some manner in the defense of the nation, have a shared culture with common expectations and needs. Similarly, veterans seeking services through the VA system experience the uniqueness of its service delivery contexts, methods, and procedures. A personal commitment to the care and well-being of former and current military personnel is embedded in the psychological service delivery culture. The pursuit and maintenance of professional competence in psychological assessment, broadly defined, is a primary activity of psychologists and psychologists in training. The terms assessment and testing are commonly used interchangeably, but the terms are not synonymous (Matarazzo, 1990). Assessment is a broader term, reflecting all methods and procedures from which psychologists can draw to help understand the emotional states, personality traits, cognitive abilities, interests, and broad spectrum of functioning of veterans. In contrast, testing refers solely to psychometric methods. A psychological assessment includes some combination of (a) record review, (b)  clinical interview of the veteran, (c)  interviews of collateral sources of information, (d) behavioral observations, and (e) psychological testing. Thus, some type of testing is commonly, but not always, a component of psychological assessment. Psychologists perform an assessment, not a testing. Testing performed in isolation, without a more comprehensive understanding of the patient’s background and current life context, is very likely to be unhelpful, at best, and more likely to be misleading and harmful. The term evaluation is an appropriate alternative term for assessment. In the assessment and care of veterans, psychologists have long worked closely with psychiatrists, neurologists, and other clinicians. While maintaining these important relationships, the opportunity for psychologists to partner with additional healthcare professionals has never been greater than it is today. Psychological assessment now informs interdisciplinary colleagues in diverse settings as an essential component of the comprehensive understanding of veterans that is needed for promoting care and well-being. While psychology continues to value its close alliance

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with those colleagues with whom long-standing relationships have been established, the opportunity to collaborate with additional professionals and to bring psychological assessment skills to new clinical settings and patient populations is also exciting. Thousands of psychologists are employed by the VA, and hundreds of students and postdoctoral residents undergo training in the VA system each year. Additional psychologists and trainees work with veterans in Department of Defense contexts, private practice, and other settings. Nearly all of the psychologists and trainees perform some type of psychological assessment. However, there has never been a text published that addresses this important topic. The closest text is Neuropsychological Practice with Veterans (Bush, 2012), which focuses primarily on neurological disorders and the neuropsychological measures used to assess them. There is some overlap between the two books, but an attempt has been made to keep such overlap to a minimum. For the purposes of this book, the term veteran refers not only to combat veterans of the current/recent wars in the Middle East, it also includes combat and noncombat veterans of all ages (adult and geriatric). The first section of this book presents the history of psychological assessment of veterans, written by a true luminary in the field. The second section covers psychological assessment of veterans in various settings, because different methods and procedures (tests, interviews, observations, review of records) are used in different settings. For example, outpatient (compared to inpatient) clinical settings typically involve higher functioning patients, so evaluations are often more comprehensive. Unique considerations apply for each setting (outpatient, long-term care, primary care, home-based primary care, and telemental health). Although a sample of settings was selected to represent the range of contexts in which psychological assessment services are provided, there are additional settings in which psychological assessment methods and procedures are applied, and clinicians in such settings may benefit from selecting aspects of the content provided in this book to use in their settings. Given the extensive literature on psychotic disorders among veterans and the comprehensiveness with which Drs. Allen and Goldstein covered the topic, two chapters (Chapters 8 and 9) were allotted to the psychological assessment of veterans with schizophrenia and other psychotic disorders. A chapter specific to inpatient psychiatry settings was not included because most of the evaluations performed in such settings are based on interviews, observations, and record reviews but do not include psychometric measures; for psychiatric patients, evaluations that involve testing are typically deferred to outpatient settings after the veterans have been discharged from the inpatient service. Additionally, because the focus of this book is on clinical (versus forensic) services, a chapter on compensation and pension (C & P) evaluations was not included. The third section addresses the assessment of a variety of disorders or presenting problems, because different measures are used to diagnose and monitor different disorders. Separate chapters address substance use disorders, psychotic disorders, mood disorders and suicidal thoughts and behavior, posttraumatic stress disorder (PTSD) and other anxiety disorders, attention-deficit/hyperactivity disorder, dementia, pain and pain-related disorders, and polytrauma. Because most of these disorders are present in civilian as well as veteran populations, the authors were asked to focus on research specific to veterans and to describe, when possible, any differences that may exist between civilians and veterans. As with assessment settings, the disorders and

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problems covered in this section represent a broad sample of the problems experienced by veterans, but other problems experienced by veterans are also confronted by psychologists and are the focus of psychological assessment. The approaches to assessment presented in the chapters in this section will also benefit clinicians who assess veterans with other disorders and problems. The fourth section covers important special considerations. The section begins with the assessment of symptom and performance validity, including malingering, which is an essential, but at times controversial, part of the assessment process. The assessment of homeless veterans and health-related quality of life are intriguing topics covered in this section. The final chapter presents ethical, legal, and professional issues. The chapter addresses the selection and use of psychological assessment measures and procedures and the ways in which the test data and results are reported and used. An attempt has been made to cover the commonly used psychological tests in one or more of the chapters. By design, there is some overlap of chapter content both within and between the sections, but an attempt has been made to avoid excessive overlap. The contributions of many colleagues were required to complete this book, and my gratitude to all cannot be overstated. I  am deeply grateful to the chapter authors for bringing their knowledge, experience, and professionalism to this project. In addition to her contribution as a chapter author, Dr.  Anne Klee was particularly helpful at the outset of the project with helping to identify other possible chapter authors. Similarly, I feel extremely fortunate that Drs. Patrick DeLeon and Paul Lewis agreed to provide the Foreword and that Dr. Bradley Karlin agreed to write the Afterword. Appreciation also goes to Drs. Bradley Axelrod and Nathaniel Nelson for their valuable input. Additionally, the book would not have been possible without the support of the psychology and mental health leadership of the VA New  York Harbor Healthcare System, including Drs. Adam Walkin, Marc Goloff, and Meredith Hostetter; I am very thankful for their support. I am also very grateful to Joan Bossert and everyone at Oxford University Press for understanding the importance of this topic and for the support offered throughout the process. Finally, as always, I am most grateful to the men and women who honorably serve or have served our nation in the armed forces. REFERENCES Bush, S. S. (Ed.) (2012). Neuropsychological practice with veterans. New York, NY: Springer Publishing Co. Matarazzo, J. D. (1990). Psychological assessment versus psychological testing: Validation from Binet to the school, clinic, and courtroom. American Psychologist, 45, 999–1017.

LIST OF CONTRIBUTORS

Daniel N. Allen, Ph.D. Department of Psychology University of Nevada, Las Vegas Las Vegas, NV Carly R. Anderson, Ph.D. Minneapolis VA Health Care System University of St. Thomas Graduate School of Professional Psychology Minneapolis, MN Paul A. Arbisi, Ph.D., ABPP, ABAP Minneapolis VA Health Care System University of Minnesota Departments of Psychiatry & Psychology Minneapolis, MN Rodney R. Baker, Ph.D. Department of Veterans Affairs, Retired San Antonio, TX Jared Benge, Ph.D., ABPP Division of Neuropsychology Baylor Scott & White Health Care Temple and Round Rock, TX Texas A&M Health Science Center Bryan, TX Christy A. Blevins Department of Psychology Auburn University Auburn, AL

Lisa A. Brenner, Ph.D., ABPP VISN 19 Mental Illness Research Education and Clinical Center (MIRECC) University of Colorado School of Medicine Department of Psychiatry Aurora, CO Shane S. Bush, Ph.D., ABPP VA New York Harbor Healthcare System Brooklyn and St. Albans, NY Stony Brook University Medical School Department of Psychiatry and Behavioral Science Stony Brook, NY Patrick H. DeLeon, Ph.D., J.D., M.P.H Uniformed Services University of the Health Sciences Bethesda, MD Former President, American Psychological Association University of Hawaii Hilo, HI Dominick DePhilippis, Ph.D. Center of Excellence in Substance Abuse Treatment and Education (CESATE) Philadelphia VA Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, PA

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Katherine M. Dollar, Ph.D. Office of Mental Health Operations VA Central Office Washington, DC Department of Community Health and Health Behavior, University at Buffalo State University of New York Buffalo, NY Michael L. Drexler, Ph.D. San Francisco VA Medical Center San Francisco, CA Gerald Goldstein, Ph.D., ABPP VISN-IV Mental Illness Research Education and Clinical Center (MIRECC) VA Pittsburgh Healthcare System Pittsburgh, PA Jessica D. Goodman, Ph.D. Center of Excellence in Substance Abuse Treatment and Education (CESATE) Philadelphia VA Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, PA B. Heath Gordon, Ph.D. G. V. (Sonny) Montgomery Veterans Affairs Medical Center Jackson, MS Susan R. Green, Psy.D., ABPP VA New York Harbor Healthcare System New York University Medical School Department of Psychiatry New York, NY Diana M. Higgins, Ph.D. VA Boston Healthcare System Boston, MA

L ist of C ontributors

James B. Hoelzle, Ph.D. Minneapolis VA Health Care System Minneapolis, MN Marquette University Milwaukee, WI Beeta Y. Homaifar, Ph.D. VISN 19 Mental Illness Research Education and Clinical Center (MIRECC) Denver, CO University of Colorado School of Medicine Department of Psychiatry Aurora, CO Michele J. Karel, Ph.D. Mental Health Services VA Central Office Washington, DC Bradley E. Karlin, Ph.D. Education Development Center New York, NY Department of Veterans Affairs Central Office Washington, DC Bloomberg School of Public Health Johns Hopkins University Baltimore, MD Lisa K. Kearney, Ph.D., ABPP Office of Mental Health Operations VA Central Office Washington, DC Department of Psychiatry University of Texas Health Science Center at San Antonio Paul R. King, Ph.D. VA Center for Integrated Healthcare Buffalo, NY

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Anne S. Klee, Ph.D. VA Connecticut Healthcare System West Haven, CT Yale University School of Medicine Department of Psychiatry New Haven, CT

Nathaniel W. Nelson, Ph.D., ABPP University of St. Thomas Graduate School of Professional Psychology Minneapolis VA Health Care System Minneapolis, MN

Daniel J. Lee Department of Psychology Auburn University Auburn, AL

Jennifer Olson-Madden, Ph.D. VISN 19 Mental Illness Research Education and Clinical Center (MIRECC) Denver, CO University of Colorado School of Medicine Department of Psychiatry Aurora, CO

Andrea Levine, M.S. VA Boston Healthcare System Boston, MA Paul C. Lewis, Ph.D., FNP-BC Colonel, US Army Uniformed Services University of the Health Sciences Bethesda, MD John Linck, Ph.D., ABPP-CN Oklahoma City VAMC Oklahoma Health Sciences Center Oklahoma City, OK Bridget Matarazzo, Psy.D. VISN 19 Mental Illness Research Education and Clinical Center (MIRECC) Denver, CO University of Colorado School of Medicine Department of Psychiatry Aurora, CO James R. McKay, Ph.D. Center of Excellence in Substance Abuse Treatment and Education (CESATE) Philadelphia VA Medical Center Perelman School of Medicine University of Pennsylvania Philadelphia, PA

John D. Otis, Ph.D. VA Boston Healthcare System Boston, MA Mark A. Sandberg, Ph.D., ABPP Northport VAMC Northport, NY Howard R. Steinberg, Ph.D. VA Connecticut Healthcare System West Haven, CT Yale University School of Medicine Department of Psychiatry New Haven, CT S. Marc Testa, Ph.D. Sinai Hospital of Baltimore The Sandra and Malcolm Berman Brain & Spine Institute Baltimore, MD Travis H. Turner, Ph.D. Ralph H. Johnson VA Medical Center Medical University of South Carolina Charleston, SC

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Christina L. Vair, Ph.D. VA Center for Integrated Healthcare Department of Psychology University at Buffalo State University of New York Buffalo, NY

Matthew S. Yoder, Ph.D. Mental Health Services VA Central Office Washington, DC Medical University of South Carolina Charleston, SC

Frank W. Weathers, Ph.D. Department of Psychology Auburn University Auburn, AL

Sandra Zinn, Ph.D. Durham VA Medical Center Department of Psychiatry Duke University Medical Center Durham, NC

Laura O. Wray, Ph.D. VA Center for Integrated Healthcare Department of Psychology, University at Buffalo State University of New York Buffalo, NY

ABOUT THE EDITOR

Shane S.  Bush, Ph.D., ABPP earned his doctorate from the California School of Professional Psychology and completed his internship training in the Department of Psychiatry at Yale University School of Medicine. He is a neuropsychologist with the VA New York Harbor Healthcare System, Director of Long Island Neuropsychology, P.C., and Clinical Assistant Professor in the Department of Psychiatry and Behavioral Science at Stony Brook University School of Medicine. He is board certified in clinical psychology, rehabilitation psychology, and neuropsychology. He is a Fellow of the American Psychological Association (Divisions 12, 20, 22, 40, 42). He is a Past President and Fellow of the National Academy of Neuropsychology. He has published more than 15 books and special journal issues, as well as dozens of articles and book chapters. He has presented at national and international conferences. He is a veteran of both the US Marine Corps and Naval Reserve.

PART ONE

Foundations

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History of the Psychological Assessment of Veterans R O D N E Y R . BA K E R

The early history of psychology as a health care profession was grounded in its focus on the use of psychological assessment to help understand normal and abnormal behavior. Prior to World War II, psychological assessment mostly defined the role of practicing psychologists. This chapter will describe the development of psychological assessment of veterans in the Veterans Administration, now named the Department of Veterans Affairs (VA). However, the history of assessment practice by psychologists working with the US Army prior to World War II or in war-related jobs during that war provides an introduction to early assessment activities in the VA and will be summarized first. The fact that a number of these war-era psychologists joined the VA as staff lends relevance to including their experience. In order to avoid overlap with the chapters written by other authors in this book, the history of assessment practices in the VA will be primarily presented as they were first introduced during the years 1946 to 1986. Other chapters will present the continued history and current practices and recommendations for instruments and procedures used for the assessment of veterans in the VA today. PRE-1946 PSYCHOLOGICAL ASSESSMENT ACTIVITIES Prior to the end of World War II, the assessment activities of psychologists in military settings were first used to evaluate soldiers, both to help the Army screen recruits to determine if they might be unsuitable for military service or combat and to make recommendations for the treatment of those admitted to Army and Navy hospitals.1 The latter assessments generally included some measure of intellectual functioning and measures of reasoning and decision-making. For those in treatment for whom 1. Unless otherwise noted, the information in this section is taken from Benjamin and Baker (2004).

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occupational therapy was being considered, tests of vocational interests and aptitudes were added. The first personality tests used by clinical psychologists were based on word association instruments. By the 1930s, psychologists began using the Rorschach Inkblot Method and the Thematic Apperception Test (TAT). These latter projective instruments were firmly established in the 1940s to assess personality; only in the 1970s did they begin to lose popularity due to concerns with reliability and validity. The final development of early psychological assessment tools came with the emergence of research-based, objective personality tests. The most well-known and frequently used instrument in this category was the Minnesota Multiphasic Personality Inventory (MMPI), first introduced in 1943. By the time the United States entered World War II, psychologists were using measures of intelligence, personality, vocational interest and aptitude, and other tests of functioning in a variety of settings. During the war, psychologists used their assessment skills in such areas as recruitment, training, equipment design, and propaganda, as well as in developing attitude surveys, testing prisoners of war, intelligence work, and conducting personality studies. Psychology’s role in the war earned the respect of the federal government and led to a 1942 federal mandate for the VA and the US Public Health Service to expand the training of clinical psychologists and other mental health professionals. With the resources devoted to the war, nothing came of this mandate, but government support of psychology, especially clinical psychology, was set for unprecedented growth in postwar graduate training programs (Baker & Pickren, 2007). THE BEGINNING OF VA PSYCHOLOGY IN 1946 With the end of World War II, 16  million active military personnel would be returning home, and 12 million left military service in the first years after the end of the war. As veterans, they would be seeking the health care promised them as part of their military service. The VA, with shortages of health care personnel (who had volunteered for military service along with other Americans), needed an infusion of staff to take care of the returning veterans. President Harry S. Truman asked General Omar Bradley, the popular general of the European forces during World War II, to assume the leadership of the VA and to provide the needed health care for the anticipated surge in returning veterans. Accepting the additional challenge to provide the best health care possible for veterans, Bradley put together a distinguished leadership team to reorganize the VA health care system to meet these goals (Baker, 2012). Legislation supporting Bradley’s reorganization plan was signed into law by President Truman in January 1946 and addressed the primary goal of improving the quality of care of veterans. First, affiliation agreements were authorized with medical schools to train their students in the VA and to bring with them experienced faculty for supervision. Second, clinical departments were established in the VA Central Office to develop treatment programs and provide oversight of discipline activities in VA hospitals. James G. Miller was appointed the first chief of VA psychology in 1946 and was given responsibility for developing needed psychological services for veterans in VA hospitals. In introducing the new psychology program to the profession, Miller outlined his

History

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vision for VA psychology in an article for the American Psychologist (Miller, 1946). He indicated that clinical psychologists would have three major roles: diagnostic assessment, therapy, and research. He stressed the diagnostic skills of clinical psychologists and their understanding of normal behavior and how that knowledge could be applied in treating problems of personal functioning. Miller’s vision for the VA psychology program also included his intention to hire only doctoral psychologists who had practical experience in providing psychological services. It was this plan to employ doctoral psychologists with training in psychological services that presented Miller with his first challenge. He had been given authority to hire 500 psychologists for VA hospitals. He noted, however, that barely more than that number were currently members of the American Association for Applied Psychology and were providing clinical services in the entire country; he thus concluded that the VA would have to train the psychologists he needed. He also recognized the fact that not all universities were training clinical psychologists to provide psychological services since most universities still maintained the position that the only legitimate professional activities of clinical psychologists were to teach and do research (Baker & Pickren, 2007). The absence of an organized curriculum for the training of clinical psychologists was noted by others, including Sears (1946), who described the problem in the same issue of the American Psychologist in which Miller presented his vision for VA psychology. In his 1946 article, Miller laid out his plans to ask the American Psychological Association (APA) to identify those universities that were providing training and experience in clinical services. He would then recruit graduate students for the VA’s new training program from that list. In addition to paying students an hourly salary to perform needed clinical services for veterans, under supervision, Miller would also provide consultation fees to university faculty to supervise their students’ clinical work until he could recruit sufficient numbers of VA staff psychologists to provide that supervision. With the assistance of APA, 31 universities were identified as providing training and experience in clinical work as part of their curriculum in graduate psychology. Over 200 students from 22 of these universities were recruited for the first VA psychology training class in the fall of 1946 and began providing services to VA patients (Baker & Pickren, 2007). PSYCHOLOGICAL ASSESSMENT OF VETERANS, 1946–1956 Most of what is known about the assessment and other clinical activities of psychologists and psychology trainees in the first years of the VA psychology program comes from oral history interviews and anecdotal data. The rush to implement programs and hire staff took precedence over workload reporting, and most information in annual VA reports to Congress were retrospectively obtained, especially in the first 3 years.

1946–1949 An attempt was made in the first years to track the number of psychology trainees and medical students, but the report of the number of staff positions in all disciplines

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is not considered complete due to the rapid recruitment activity and infusion of staff in the field. Official records indicate that there were only three doctoral psychologists in the VA on June 30, 1946. A year later that number had increased to 146, with 219 the year after—still far less than the 500 positions Miller had been authorized to hire. In the fall of 1946, 215 psychology students started their training and work with VA patients in hospitals around the country near their training university. That number is considered accurate since the count comes from the list of trainee names and their universities published in the American Psychologist (1947), presumably obtained from the VA. The 1947 training class numbered 460 and was officially recorded as 459 at the end of the 1948 fiscal year in the VA’s annual report to Congress (Veterans Administration, 1949). The beginning years of the VA psychology program can be best described as a learning experience for most psychologists, trainees, university supervisors, and the VA hospitals themselves. Hospitals were instructed by management officials in the VA Central Office to begin providing psychological services for their patients, and a number of hospitals hired doctoral psychologists as chiefs of psychology (with no staff) as a response. According to a number of stories told by some of these first chiefs (Baker, 2007), neither they nor the hospitals knew what they were supposed to do. Most of these new chiefs chose to begin consultation and diagnostic services throughout the hospital and, if they had been hired by one of the general medical, surgical, and psychiatric VA hospitals, the consultation would be extended to patients in medical and surgical programs as well as psychiatric programs. Psychology trainees began their VA training in a health care system that had approximately 100,000 beds and, even by the end of the 1948 fiscal year report to Congress noted earlier, 55% of those beds were occupied by psychiatric patients. Most of those beds were in turn filled by long-term, hospitalized World War I veterans with an average length of stay close to 500 days. With psychology trainees greatly outnumbering doctoral psychologists, the early story of assessment of veterans overlaps significantly with the history of VA training. Some trainees were placed in VA hospitals with only the master’s level staff presence that had predominated assessment services before 1946. Some were assigned to hospitals for training with no psychology presence. Some were assigned to general medical and surgical hospitals with an opportunity to practice all of the assessment skills they had learned in graduate school with a wide range of patients. Since 25% of VA hospitals were designated neuropsychiatric only, with large numbers of World War I patients in the aforementioned 500-day length-of-stay category, some psychology trainees had limited opportunity to practice formal assessment skills. The pre-Thorazine era of management of psychotic and aggressive patients included straitjackets, cold packs, and electroshock treatment. Trainees sharpened their assessment skills without instruments by basing assessments on observation and interactions with these patients. An early trainee assigned to one of the large neuropsychiatric hospitals with no psychology presence noted that trainees did what they had to do to help patients and learned by doing (Gurel, 1999). Gurel added that, not knowing any better, the trainees expected the patients to get better and thus energized other staff. Their supervision frequently came from their discussions with each other about the patients they were seeing. Although their university faculty did provide some supervision and

History

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on-site seminars, Gurel later noted that many university supervisors had no practical experience themselves working with active and aggressive psychotic patients and, in fact, the university supervisors learned with their students and took that learning experience back to their classrooms (Baker & Gurel, 2003). In spite of the varied difficulties facing early VA trainees, they almost universally reported that their training was a positive one with valuable learning (Baker, Stenger, Gurel, & Goldstein, 2012; Gurel, 1999; Stenger, 2003). The psychology students were young, enthusiastic, and saw the relevance and need for their training, and believed that they were in fact helping patients. Virtually all of the early trainees were veterans themselves and appreciated that they were not only learning useful clinical skills but were additionally motivated by having the opportunity to help their fellow veterans. Their own combat and military experience became even more relevant with the sharp increase in World War II veterans in VA hospitals from 1946 to 1949. Early trainees further reported that their enthusiasm and desire to help patients was respected by other VA staff and helped develop important working relationships with nurses and others.

1950–1956 The use of and respect for psychological assessment steadily grew in the 1950s. In one report, for example, Stenger told the story (Baker, 2007) of an assessment referral by a chief of neurosurgery that proved so helpful that the neurosurgeon subsequently required his residents to request psychological testing before performing surgery. The 1950s also saw psychologists emerge as therapy providers, and assessment referrals began drawing on that skill in asking for treatment recommendations. As the younger World War II veterans began entering VA hospitals with active treatment needs and shorter lengths of stay, assessment referrals now made more use of projectives and other assessment tools. By the end of the first decade of the VA psychology program, a typical assessment protocol included a Wechsler Adult Intelligence Scale (WAIS), Rorschach, TAT, and MMPI, along with any other test chosen for the specific referral question. The Bender-Gestalt and Graham-Kendall, for example, would be added for patients suspected of having some organic-based cognitive deficits— predating the formal neuropsychological assessment battery, which would soon be introduced into the VA (Baker et al., 2012). Psychologists with their assessment tools quickly found acceptance when introduced in the VA’s general medical and surgical hospitals. They and their trainees became involved in assessment and treatment consultation for patients with tuberculosis, cancer, renal dialysis, and other nonpsychiatric health problems, which we might now refer to as medical psychology programs. Assessment instruments were frequently involved in research activities with these patient groups, and many trainees used their experiences and VA patient data to plan and complete their doctoral dissertations (Baker  & Pickren, 2007). Early dissertation topics of trainees in the VA clearly stood out in subject matter from most of their non-VA graduate training classmates, as they included such areas as assessment of treatment compliance in the tuberculosis patient and assessment of depression in cancer and renal-dialysis patients.

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Psychologists were also involved in many new treatment initiatives to meet the VA’s goal of reducing the need for long-term hospitalization. They and their trainees were active participants in the VA’s new outpatient mental health clinics, for example, which provided an opportunity for psychologists to use their assessment and treatment skills to identify and select patients for early discharge from the hospital by supporting them in the home or community life with outpatient care. Counseling psychologists used their vocational rehabilitation assessment and counseling skills to identify patients who could benefit from work restoration therapy and what were then called member-employee programs (the earliest use of what we now call compensated work therapy). These programs were often designed to improve self-esteem and functioning levels of patients in the hospital, but a number of these patients were able to be discharged to community life with the new work skills and habits they had learned (Baker & Pickren, 2007; Peffer, 1955). By the end of the first decade of the VA psychology program, the amount of time psychologists were spending in assessment began declining as their time in treatment increased. The earliest report of workload activity indicated that psychologists spent over half of their time in assessment activities; by 1956, the percent time in assessment had dropped to 22% (Baker & Pickren, 2007; Wolford, 1956). Miller’s initial authority in 1946 to hire 500 doctoral-level psychologists for the VA was reached in 1953 when the VA’s workforce included 564 doctoral psychologists and 700 trainee positions. At the end of the 1956 fiscal year, there were 705 psychologists and 771 psychology trainees on the VA’s employment rolls, but the annual reports to Congress by the VA still indicated an unmet need for additional psychologists and other mental health professionals. A 1956 evaluation of the psychology training program was conducted to determine whether the program should be continued. In noting that most psychology trainees took VA staff positions after training, even without any payback requirement for doing so, the evaluation report indicated that the training program should be continued in order to help the VA recruit the psychologists it would need in future years. PSYCHOLOGICAL ASSESSMENT OF VETERANS, 1957–1967 In the second decade, psychologists entered a period of growth and innovation in developing new mental health treatment programs. The psychoanalytic approach to treatment still characterized much of psychiatry’s contributions but was being found of limited use with the VA’s seriously mentally ill patient population. The introduction of Thorazine and other psychotropic medications in the VA during the late 1950s and 1960s led to the improved ability of long-term psychiatric patients to communicate and relate more successfully with others. This in turn gave psychologists the opportunity to assess skills and resources in the patient for treatment planning that could lead to discharge with follow-up treatment support in the VA’s outpatient Day Treatment Centers and Day Hospital Programs in which psychologists played leading roles. Finally, psychologists were also introducing the same behavioral based inpatient treatment programs being used by their non-VA colleagues. These included the use of behavioral conditioning in token economy programs, as well as attitude therapy and therapeutic milieu programs (Baker & Pickren, 2007; Veterans Administration, 1965).

History

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The second decade also found VA psychologists additionally expanding and improving their assessment skills. Most notable (and described next) was the development of neuropsychological assessment services and improvements in the interpretation of the MMPI.

Neuropsychological Assessment The end of long-term hospitalization, the transition to behavioral treatment and empirical assessment, and the emergence of neuropsychological assessment in the VA are illustrated by the report of Gerald Goldstein (Baker et  al., 2012). From 1956 to 1976, Goldstein served first as a trainee and then staff psychologist at the VA hospital in Topeka, Kansas, with the prominent academic and clinical influence of both the University of Kansas and the Menninger Foundation. As token-economy and behavior therapy programs were introduced, Goldstein noted a decline in the number of psychological assessments using projective techniques and a greater reliance on the MMPI and related objective assessment instruments. All patients admitted to psychiatry participated in group testing and received the MMPI and screening for general intelligence and brain damage. During the same period, Goldstein began his own research and collaboration with neurology at the Topeka VA in evaluating the new neuropsychological assessment instruments. Following the establishment of a neuropsychology program at the Menninger Foundation, and with strong support of neurology and the chief of psychology, Goldstein established a neuropsychological laboratory at the Topeka VA to provide neuropsychological assessment services to VA patients. Goldstein’s early activity in neuropsychological assessment research and the establishment of his neuropsychology laboratory were not unique in the VA. However, in the publication of his keys work with Russell and Neuringer, Goldstein credits his collaboration with neurology and his statistician wife for being responsible for the development of the first automated scoring and interpretation program in neuropsychological assessment (Russell, Neuringer, & Goldstein, 1970).

The Actuarial Development of the MMPI As noted previously, the MMPI was first introduced in 1943 and quickly became one of the most frequently used assessment tools in both VA and non-VA settings. The MMPI was additionally used in a wide range of research studies to compare scores between different patient populations and to assess treatment progress. It was the research work of Harold Gilberstadt with the MMPI at the VA Hospital in Minneapolis, however, that was responsible for one of the major changes in the interpretation of the MMPI. Prior to Gilberstadt’s work, the interpretation of the results of the MMPI was primarily based on pattern and profile analysis. Gilberstadt and his many research collaborators added an empirical interpretation of the MMPI scales in the publication of their Handbook for Actuarial MMPI Interpretation (Gilberstadt & Duker, 1965). PSYCHOLOGICAL ASSESSMENT OF VETERANS AFTER 1967 Changes in patient care services provided by psychologists and psychology interns in the post-1967 era continued to show a decline in time spent in assessment activities,

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with an increase in time spent in individual and group therapy. By 1986, assessment time had fallen to 15–20% of time spent in direct patient care activities, but the variety of assessment practices had expanded. Interview-based assessment, including a review of the medical record and military history with the patient, was frequently used in assessing patients referred for transfer or admission to a treatment program. Questionnaire-based assessments using the MMPI and other objective tests would sometimes be added to referrals. A full psychological test battery, including the WAIS, Rorschach, TAT, and appropriate objective tests, was yet another assessment category being used by staff and being taught to psychology interns. Brief and full neuropsychological assessment batteries had gained more importance, and computer-assisted testing had also begun to assume prominence in completing assessment referrals (Baker, Barrett, & Klauck, 1986).

Automated Psychological Assessment The origins of computer-assisted or automated psychological assessment of patients in the VA can be traced to three initiatives. The first was the VA’s goal of establishing a computerized medical record that could eventually be shared among treatment staff in all VA hospitals. Second, mental health leaders in the field and in the VA Central Office began to develop a plan to continue the development of software that automated the administration and scoring of psychological instruments, but to do so in a way that the software could be included in the electronic medical record. Finally, the VA began installing personal computers in VA staff offices to facilitate the entry of electronic progress notes and other information into the medical record. The use of personal computers in psychology offices for electronic treatment notes and the placement of personal computers in psychology testing labs would in turn support the use of personal computers for automated psychological assessment (Baker  & Pickren, 2007). One of the first comprehensive programmatic uses of automated psychological testing occurred at the VA hospital in Salt Lake City, Utah, with the evaluation of all new psychiatry admissions. The inclusion of the results of automated assessments in the electronic medical record, however, faced a difficult path, since the VA had decided to use a little-known programming language developed at the Massachusetts General Hospital. Gottfredson noted that previously developed automated assessment software had to be modified to satisfy stringent criteria for the new programming language before the software could be approved for use in the electronic medical record (Baker, 2007). With mental health leaders in the VA Central Office continuing to push the initiative, the automated psychological assessment program became fully integrated into the VA’s electronic medical record in 1985. Although automated assessment programs were being developed outside the VA, it was the innovation of integrating and storing assessment data in an electronic patient care record database that improved patient care and has still not been adopted elsewhere on as large a scale. Psychologists who were evaluating patients previously seen in another VA hospital could now access earlier assessment data to compare current functioning of the patient with that found in the past. The program also ensured accurate scoring of tests and scales using the same standards in all hospitals.

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Over the years, psychological tests such as the MMPI and behavioral rating scales such as the Beck Depression Inventory were augmented with other tests and rating scales. In fiscal year 2004, there were 55 instruments and 24 clinical interviews in the automated psychological assessment program, which saw the storage of over 2.1 million assessments (Baker & Pickren, 2007). According to the current director of Informatics in the VA’s Office of Mental Health Services, fiscal year 2011 added the results of 14.2 million assessments to the VA’s electronic medical record for 4.6 million unique patients (K. Lysell, personal communication, November 1, 2012).

Assessment of PTSD The 1970s and 1980s brought large numbers of Vietnam veterans into VA hospitals, many of whom sought treatment for the lingering effects of their combat experiences. Their symptoms often mirrored those of World War II combat veterans treated for war neuroses or other diagnoses generically referred to as “combat-fatigue.” The prevalence as well as differences of these symptoms among Vietnam veterans, however, eventually led the VA and the military to use the recently introduced diagnosis of post-traumatic stress disorder, or PTSD. Although the VA had always sought treatment program ideas from the non-VA sector in developing treatment programs, that sector had little to offer in this area, since their experience with PTSD was limited to trauma cases in such areas as sexual assault and natural disasters. The VA and the military had to develop their own assessment and treatment protocols for use with combat-related PTSD. In addition to a good medical and military history review with the patients, VA psychologists and other clinicians initially used a variety of assessment instruments that included the word “stress” or “trauma” evaluation in their titles to diagnose PTSD, but most of these latter instruments were found to be inadequate. Subsequently, VA psychologists began designing interview scales and other instruments based on their experiences in working with Vietnam veterans and additionally generated the needed research to assess the reliability and validity of their scales. One early assessment instrument, still being used today, was the Mississippi Scale for combat-related PTSD (Keane, Caddell, & Taylor, 1988). In the 1980s, the VA initiated two major projects to assist clinicians in the understanding of the Vietnam veteran experience and the development of effective strategies for assessment and treatment of PTSD. The first was the National Vietnam Veterans Readjustment Study (NVVRS), and the second was the establishment of the VA’s National Center for PTSD. The NVVRS was one of the most comprehensive studies of a veteran population ever undertaken by the VA. The study described the range of difficulties experienced by the Vietnam veteran in a wide area of marital, social, and intrapersonal functioning, including comorbid problems of depression and other diagnoses that often accompanied PTSD. The study further confirmed that 30% of males assigned to duty in Vietnam met the criteria for PTSD, with 27% of females meeting the same criteria (Kulka et al., 1988). The National Center for PTSD was established in the VA in 1989 to address the needs of veterans with military-related PTSD and to serve as a center for excellence in research and education (see Department of Veterans Affairs, n.d.). With its own

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research and research spawned by the center, reliable and valid assessment instruments of PTSD began to emerge. The continued development of PTSD assessment instruments by the center and other researchers are today being used by VA psychologists to provide PTSD assessment for combat veterans with military service in Iraq and Afghanistan, and the use of these instruments will be expanded in a later chapter in this book (see Chapter 11, Psychological Assessment of Veterans with PTSD and Other Anxiety Disorders, by Blevins, Lee, & Weathers). By June 1988, the VA had established 60 inpatient and 66 outpatient PTSD programs in its hospitals that were providing assessment and treatment services for Vietnam veterans. In addition, 30 PTSD treatment teams had been funded to provide specialized services to these veterans (Baker & Pickren, 2007).

Geropsychology Assessment As noted earlier, large numbers of Vietnam as well as Korean War veterans sought treatment in the VA in the post-1967 era and needed the development of new assessment protocols to treat PTSD and other problems. Even though these younger veterans comprised a significant number of the VA’s treatment population, it was still small when compared to the even larger number of aging World War II veterans receiving treatment in the VA. This elderly patient population also needed new approaches to assessment in such areas as competency, the ability to function in social and interpersonal situations, and skill-based assessments for independent living. Psychologists and other health providers in the VA assumed pioneering and leadership roles in geropsychology assessment, including the development, evaluation, and use of a variety of instruments designed to reliably assess activities of daily living and instrumental activities of daily living. In addition, assessments of social functioning and adaptation had to be updated or developed to help make treatment and discharge decisions. In 1996, the VA revised an earlier catalog of instruments and rating scales for use in assessments of the elderly and published a comprehensive list of assessment tools with annotated comments on their use with the elderly (Department of Veterans Affairs, 1996). Many of these instruments and rating scales were added to the automated psychological assessment program described earlier, which today include such instruments as the Barthol Index of Activities of Daily Living, the Lawton-Brody Instrumental Activities of Daily Living Scale, and the Quality of Life Inventory. In 1997, the VA also published one of the first practice guidelines for psychologists in the assessment of competency of the older adult (Baker, Lichtenberg, & Moye, 1998; Department of Veterans Affairs, 1997). SUMMARY Psychological assessment formed the core of patient care activities of psychologists and their trainees with the beginning of the VA’s psychology program in 1946. Although the time spent in assessment activities fell as psychologists became more involved in treatment activities, VA psychologists retained their historical roots and skills in assessment as they developed new instruments to meet the needs of emerging VA patient populations in specialized areas such as neuropsychological, PTSD, and geropsychology assessment.

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Today, the VA’s psychology workforce includes over 3,700 psychologists with almost 700 annually funded, APA-accredited internship and postdoctoral training positions. The remaining chapters in this book will document the VA’s current assessment programs and practices of this workforce in a wide range of treatment settings in inpatient and outpatient mental health treatment, long-term care, primary care, and telehealth treatment programs. Other chapters will describe state-ofthe-art assessment activities with an equally diverse diagnostic population, ranging from patients with psychotic and substance use disorders to PTSD and dementia disorders to the more recent use of assessments with polytrauma and traumatic brain-injured patients. These chapters will, in fact, demonstrate that the challenge President Truman gave to General Bradley after World War II to provide the best care possible for veterans is still alive and is guiding the present-day assessment activities of psychologists in the VA. REFERENCES American Psychologist (1947). Psychological Notes and News. 2, pp. 184–185. Baker, R. R. (Ed.). (2007). Stories from VA psychology. Bloomington, IN: Authorhouse. Baker, R.  R. (2012). Historical contributions to veterans healthcare. In T. W.  Miller (Ed.), Praeger Handbook of Veterans Health: Vol. 1. History, Veterans Eras and Global Healthcare (pp. 3–23). Westport, CT: Praeger Security International. Baker, R. R., Barrett, J., & Klauck, K. (1986, August). Productivity standards for psychology staffing in treatment institutions. Paper presented at the annual meeting of the American Psychological Association, Washington, DC. Baker, R. R., & Gurel, L. (2003, August). The VA affiliation contribution to the development of clinical psychology. In W. E. Pickren (Chair), Growth stimulus: Federal funding of American psychology after World War II. Symposium conducted at the annual meeting of the American Psychological Association, Toronto, Canada. Baker, R. R., Lichtenberg, P. A., & Moye, J. (1998). A practice guideline for assessment of competency and capacity of the older adult. Professional Psychology: Research and Practice, 29, 149–154. Baker, R.  R.,  & Pickren, W.  E. (2007). Psychology and the Department of Veterans Affairs: A historical analysis of training, research, practice, and advocacy. Washington, DC: American Psychological Association. Baker, R. R., Stenger, C., Gurel, L., & Goldstein, G. (2012). Patient care by VA psychologists in the 1950s and 1960s. Psychological Services, July 30, 2012. No pagination specified. doi:10 1037/a0029515. Benjamin, L. T., & Baker, D. B. (2004). From séance to science: A history of the profession of psychology in America. Belmont, CA: Wadsworth/Thomson Learning. Department of Veterans Affairs. (n.d.) National Center for PTSD:  Mission and overview. Retrieved September 10, 2012, from http://www.ptsd.va.gov/about/mission/ mission-and-overview.asp Department of Veterans Affairs. (1996). Geropsychology assessment resource guide, 1996 revision. Milwaukee, WI:  National Center for Cost Containment (NTIS No. PB96-144-365). Department of Veterans Affairs. (1997). Assessment of competency and capacity of the older adult: A practice guideline for psychologists. Milwaukee, WI: National Center for Cost Containment (NTIS No. PB97-147-904).

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Gilberstadt, H., & Duker, J. (1965). A handbook for clinical and actuarial MMPI interpretation. Philadelphia, PA: W. B. Saunders. Gurel, L. (1999, August 11). Oral history with Wade Pickren [Transcript]. (Available from American Psychological Association, 750 First Street NE, Washington, DC 20002). Keane, T. M., Caddell, J. M., & Taylor, K. L. (1988). Mississipi Scale for combat-related posttraumatic stress disorder:  Three studies in reliability and validity. Journal of Consulting and Clinical Psychology, 56, 85–90. Kulka, R.  A., Schlenger, W.  E., Fairbank, J.  A., Hough, R.  L., Jordan, B.  K., Marmar, C.  R.,  & Weiss, D.  S. (1988). National Vietnam Veterans Readjustment Study (NVVRS):  Description, current status, and initial PTSD prevalence estimates. Washington, DC: Veterans Administration. Miller, J.  G. (1946). Clinical psychology in the Veterans Administration. American Psychologist, 1, 181–189. Peffer, P.  A. (1955, March). The member-employee program:  Department of Medicine and Surgery program guide for psychiatric and neurology service (G-1, M-2, Pt. X). Washington, DC: Veterans Administration. Russell, E.  W., Neuringer, M.  S.,  & Goldstein, G. (1970). Assessment of brain damage: A neuropsychological key approach. New York, NY: Wiley-Interscience. Sears, R.  R. (1946). Graduates training facilities:  I.  General information; II. Clinical Psychology. American Psychologist, 1, 135–150. Stenger, C. A. (2003, December 3). Oral history with Wade Pickren [Transcript]. (Available from American Psychological Association, 750 First Street NE, Washington, DC 20002). Veterans Administration. (1949). Administrator of Veterans Affairs annual report to fiscal year ending June 30, 1948. Washington, DC: US Government Printing Office. Veterans Administration. (1965). VA psychology in the mid-sixties: Trends and developments. (Available in the Archives of the History of American Psychology, University of Akron, Akron, OH.) Wolford, R.  A. (1956). A review of psychology in VA hospitals. Journal of Counseling Psychology, 3, 243–248.

PART TWO

Contexts

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Psychological Assessment of Veterans in Outpatient Mental Health Settings NAT H A N I E L W. N E L S ON, CA R LY R . A N D E R S ON, JA M E S B. H O E L Z L E , A N D PAU L A . A R B I S I

Veterans who establish care within the Veterans Administration (VA) system represent a remarkably heterogeneous group who often present with a variety of medical, as well as mental health, conditions. Mental health difficulties may relate to premorbid vulnerabilities, previous military service activity itself (e.g., combat), post-separation life events, and for some veterans, an admixture of these factors. While researchers have not consistently demonstrated increased risk of psychiatric disorder on the basis of veteran status alone (cf., Bohnert et al., 2012; Dichter et al., 2012; Freedy et  al., 2010; Kaplan et  al., 2012; White, Barber, Azrael, Mukamal,  & Miller, 2011), the reality is that mental health conditions such as post-traumatic stress disorder (PTSD; Freedy et al., 2010; Gates et al., 2012; Gros et al., 2011), major depression (Gadermann et  al., 2012), substance abuse/dependency (White et  al., 2011), obsessive compulsive disorder (Gros et al., 2013), and panic disorder (Gros et  al., 2011)  are of high and concerning prevalence in veteran samples. Research also suggests that veterans with mental health conditions who rely on primary care services alone have worse general medical prognoses relative to those who seek specialized mental health services (Kilbourne et al., 2010), and certain mental health conditions, such as alcohol/drug dependence and schizophrenia, have been identified as having an independent association with overall mortality in veteran samples, even after controlling for medical comorbidities and physical health factors (Chwastiak et al., 2010). Taking this information together, it is clear that continued investment in mental health services within the VA system, including development of high-quality psychological assessment resources, is warranted. The psychological assessment needs of veterans often vary by cohort and era of previous military service. The psychological needs of World War II–era and other aging veterans, for example, may be quite distinct relative to those who have served more recently, related to the high prevalence of comorbid psychiatric (e.g., depression) and

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neuropsychiatric (e.g., delirium, dementia) conditions (Goy & Ganzini, 2011) that may prompt a thorough assessment of psychological as well as cognitive functioning. The high prevalence of post-traumatic stress and other emotional difficulties among Vietnam veterans (Holowka, Marx, Kaloupek, & Keane, 2012) may result in a formal psychological assessment of post-tramautic stress disorder (PTSD) or other anxiety disorder, while the medically unexplained physical symptoms of certain Gulf War veterans (Binder  & Campbell, 2004)  may prompt psychological assessment of an underlying somatoform disorder or other psychological condition. The recent wars in Iraq (previously Operation Iraqi Freedom, OIF; later Operation New Dawn, OND) and Afghanistan (Operation Enduring Freedom, OEF) have spawned increased demand for psychological assessment services in VA outpatient mental health settings. OIF/OND/OEF veterans present with frequent reports of physical, psychological, and emotional difficulties that often persist well after soldiers return from the combat theater. OIF/OND/OEF soldiers confront blast events with alarming regularity, rendering them vulnerable not only to potentially debilitating physical injury (e.g., loss of limb, traumatic brain injury) but impairing psychological injury as well. The transition to civilian life can be difficult; a meaningful proportion of OIF/OND/OEF veterans develop problematic patterns of substance use (Widome et al., 2011), chronic PTSD and associated relational difficulties (Erbes et al., 2011), sexual dysfunction (Nunnink, Fink, & Baker, 2012), depression (Hoge et  al., 2008), and chronic pain (Stecker et  al., 2010). Veterans with histories of deployment-related injury, probable PTSD, and depression are also at increased risk of sustaining further physical injury during the post-deployment phase (Carlson et al., 2011). It follows that effective assessment and treatment of psychological conditions may reduce risk of post-deployment injury. Clinical psychologists who provide psychological assessment services in VA outpatient mental health settings play an integral role in establishing a well-informed differential diagnosis that may have profound implications for the overall health, quality of life, and long-term functional outcomes of military veterans. This chapter provides an overview of fundamental assessment strategies for psychologists to consider when providing outpatient assessment services on behalf of military veterans within the VA system of care. Comprehensive psychological assessment entails the integration of information obtained through review of previous screening results, thorough clinical interviewing, and the appropriate administration and interpretation of standardized psychological and cognitive instruments. In this context, we organize the chapter through a sequential discussion of the following topics: • Screening instruments: instruments commonly administered (and sometimes mandated) through the VA, their strengths and weaknesses, and factors to consider when reviewing screening results prior to outpatient mental health assessments. • Clinical interview: a critical component of psychological assessment that allows the clinician to obtain essential background information that may or may not come to light through the administration of formal psychological tests alone. Through a brief review of unstructured and structured interview strategies, we attempt to highlight background self-report information that can be complemented with objective test results, and that may ultimately support an integrated and well-informed diagnosis.

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• Self-report measures and projective methods: the Minnesota Multiphasic Personality Inventory (MMPI-2), its Restructured Form (MMPI-2-RF), and other common extended personality inventories are reviewed, followed by a review of strengths and weaknesses associated with projective techniques, the Rorschach in particular. • Cognitive tests: a brief summary of cognitive instruments that general practitioners of clinical psychology may consider for the assessment of veterans with nonspecific cognitive complaints, and to identify whether a more thorough clinical neuropsychological evaluation might be clinically indicated. We conclude with a brief discussion of the American Psychiatric Association’s Diagnostic and Statistical Manual, fourth edition, text revision (DSM-IV-TR) and fifth edition (DSM-5), and the lack of clarity that exists (at the time of current writing) regarding the use of the DSM-5 within VA mental health settings. We provide an example of just one condition (PTSD) that has undergone a fairly substantial revision through DSM-5, and encourage the reader to develop a more comprehensive knowledge of DSM-5 revisions across conditions. SCREENING INSTRUMENTS AND FACE-VALID SELF-REPORT MEASURES Upon initial consultation with VA providers, veterans typically complete a number of screening measures to guide additional referrals for any necessary services. The VA has instituted various screening instruments meant to identify individuals who may be at risk for mental health difficulties. Screening instruments have been implemented for such conditions as PTSD, depression, and problematic alcohol use. Although these instruments come with their own potential limitations, including unclear or high false positive identification rates (e.g., Vanderploeg  & Belanger, 2013), they nevertheless assist the ability to identify those veterans who may benefit from a more comprehensive assessment by a clinical psychologist (Chavez et al., 2012; Yano et al., 2010). Veterans often first present to primary care, at which time they complete screening measures or “clinical reminders” to assess for symptoms of PTSD (e.g., PC-PTSD, PCL), depression (PHQ-9, BDI-II), anxiety (BAI), alcohol use disorders (AUDIT), and traumatic brain injury (VAT-BIST, or the TBI clinical reminder screen). The goal of brief screening in the primary care setting is not for diagnostic purposes but rather to cast a wide net, to steer veterans toward appropriate services, and ultimately to reduce healthcare costs.

Screening of Depression and Anxiety A recent meta-analysis showed the prevalence of major depressive disorder in US military personnel to be 12% in those currently deployed and 13.1% in those previously deployed (Gadermann et al., 2012). Consistent correlates of these prevalence estimates included being young (ages 17–25), female, enlisted, unmarried, and having less than a high school education (Gadermann et  al., 2012). Given these estimates, screening of depression is essential for optimal patient care.

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The Patient Health Questionnaire-9 (PHQ-9) is a valid and reliable measure of depression severity and comprises nine items that encompass the depression module of the original PHQ (Kroenke, Spitzer, & Williams, 2001). The PHQ-9 addresses each of the nine DSM-IV-TR criteria for major depressive disorder, and respondents rate each symptom on a 4-point (0 to 3) rating scale, resulting in 27 total possible points. Using a PHQ-9 cut score of ≥10 demonstrated sensitivity and specificity of 88% for major depression, with scores of 5, 10, 15, and 20 denoting mild, moderate, moderately severe, and severe symptoms of depression, respectively (Kroenke, Spitzer, & Williams, 2001). A major advantage of the PHQ-9 is that it is brief, with less than half the items of other depression-screening measures, yet it also demonstrates comparable psychometric properties to other instruments (Kroenke, Spitzer, & Williams, 2001). For this reason, the PHQ-9 is the preferred annual depression screener used in busy and time-constrained VA primary care settings; it may arguably be extended to a wide variety of clinical settings.

Screening of Post-traumatic Stress Disorder Primary Care-PTSD Screen (PC-PTSD) The Department of Defense (DoD) and the Veterans Health Administration (VHA) have mandated the administration of the PC-PTSD, a screening instrument comprising four dichotomous (yes/no) items that assess PTSD symptoms related to nightmares/re-experiencing, hyperarousal, avoidance, and numbing (Prins et al., 2003). Scores range from 0 to 4; when using cutoffs of ≥3, the PC-PTSD has been found to have adequate sensitivity (0.70–0.91) and specificity (0.80–0.97; for review, see Tiet, Schutte, & Leyva, 2013). A recent study by Tiet and colleagues (2013) showed that using a cut-point of ≥4 led to optimal efficiency (0.76), though this significantly decreased the measure’s sensitivity (from 0.79 to 0.67). Within the VA, a score of 3 or greater warrants brief discussion of symptoms and their functional impact as well as suggestion of more comprehensive diagnostic mental health evaluation.

PTSD Checklist (PCL) The PCL (Weathers, Litz, Herman, Huska,  & Keane, 1993)  is a brief, self-report screening measure originally developed by a research group from the National Center for PTSD. Since its development, the PCL has become one of the most widely used measures for assessment of PTSD (Elhai, Gray, Kashdan,  & Franklin, 2005). There are three current forms of the PCL, including the military (PCL-M; Weathers et al., 1994), civilian (PCL-C; Weathers et al., 1994), and specific (PCL-S; Weathers et al., 1994) versions, designed to address differences in the index traumatic event. To our knowledge, no study has directly compared the psychometric properties of these three instruments (McDonald & Calhoun, 2010). All measures are composed of 17 items developed to assess the range of PTSD symptoms. Respondents rate how bothered they have been by the various symptoms over the past month on a scale from 1 (not at all) to 5 (extremely), resulting in 85 total possible points. Early research investigating the psychometric properties of the PCL revealed optimal diagnostic efficiency of 0.90 using a cutoff score of 44 (Blanchard, Jones-Alexander, Buckley, & Forneris, 1996). The total PCL score was also shown to

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be highly correlated (r = .93) with clinician ratings on the Clinician Administered PTSD Scale (CAPS; Blake et  al., 1995), though greater variability was reflected in the individual items (r  =  0.39 to 0.79; Blanchard, Jones-Alexander, Buckley,  & Forneris, 1996). More recent literature has shown the PCL to be psychometrically sound with regard to test-retest reliability, internal consistency, and convergent validity (for review, see Wilkins, Lang, & Norman, 2011). However, concerns have been raised about the discriminant validity of the PCL due to moderate-to-high correlations observed between the PCL and measures of anxiety, depression, general quality of life, and other disorders primarily involving negative affect and distress (Wilkins, Lang, & Norman, 2011). Indeed, research has demonstrated linear associations between PCL-M, Beck Depression Inventory, 2nd edition (BDI-II), and CAPS diagnosis, suggesting that these screening measures may indicate general distress, as opposed to specific PTSD symptoms (Arbisi et al., 2012). Practitioners and researchers are therefore encouraged to be aware of the diagnostic limitations of the PCL, as it is difficult to distinguish symptoms of PTSD from those of other highly comorbid psychological disorders. Additional literature has highlighted context-specific factors that limit the diagnostic utility of the PCL. In a longitudinal investigation of National Guard soldiers returning from combat deployment, Arbisi and colleagues (2012) showed differences in required cutoffs in treatment-seeking and nontreatment-seeking samples. Specifically, a raw score of 45 was designated as the optimal cutoff for a nontreatment-seeking sample, with 6.5% base rate of PTSD based on DSM-IV-TR criteria; this score optimized sensitivity and specificity, but still produced a high false positive rate of 69%–78% over time. Conversely, the accuracy of cut scores has been shown to vary greatly, dependent on the prevalence of PTSD in treatment-seeking samples (i.e., cut scores of less than 44 overestimate the concurrent prevalence of PTSD in samples with actual prevalence of 15% or less; scores of 44 or greater underestimate the concurrent prevalence when actual prevalence is greater than 35%; see Arbisi et al., 2012). Consequently, the use of the PCL in nontreatment-seeking populations is not recommended, as base rates of PTSD in these samples are lower, and therefore any cut score (typically selected in the VA to optimize sensitivity vs. specificity) is likely to overestimate the prevalence of persisting PTSD (Arbisi et al., 2012). The VA has mandated use of the PCL as a primary outcome measure for veterans engaged in active treatment for PTSD in efforts to establish national PTSD outcome data. Wilkins and colleagues (2011) highlighted the difficulty of determining the ability of the PCL to assess treatment-related change, as studies often report test-retest correlations without specifying any change in mean scores. Only two studies have investigated the PCL’s sensitivity to change, with conflicting results (see Wilkins, Lang, & Norman, 2011). Until this problem is resolved, the PCL should be used cautiously to assess treatment-related change.

Screening of Substance Use Disorders Substance use disorders (SUDs) are highly prevalent in military service personnel and veterans, particularly related to alcohol and nicotine dependence. Such disorders are of paramount concern, as they have a significant impact on personal and occupational functioning. Accordingly, the DoD and the VA have established

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evidence-based practices for the assessment, diagnosis, and treatment of SUDs to identify patients at risk and to promote optimal intervention (see Hawkins, Malte, Imel, Saxon, & Kivlahan, 2012). Annual screening has been implemented for alcohol and tobacco use; screening for illicit substances in the primary care setting is recommended only for certain high-risk populations (e.g., hepatitis C, HIV positive, serious mental illness/suicidal; see Hawkins, Malte, Imel, Saxon, & Kivlahan, 2012). In the VA setting, yearly tobacco screening involves asking patients whether or not they use tobacco; following positive responses, providers advise patients to consider cessation and determine the patient’s current interest in attaining abstinence (Hawkins, Malte, Imel, Saxon, & Kivlahan, 2012). Due to initial discrepancies between provider query/advisement (95%) and patient engagement in smoking cessation therapy (< 10%), the VA implemented a series of policies aimed to increase use of nicotine replacement therapy (NRT) and bupropion for those interested in quitting. Since the implementation of these policies, the rates of prescribed NRTs have increased substantially (see Hawkins, Malte, Imel, Saxon, & Kivlahan, 2012). The standard screening instrument for problematic alcohol use is the Alcohol Use Disorders Identification Test Consumption Questions (AUDIT-C; Bush et al., 1998). Research has indicated adequate psychometric properties in general outpatient (Reinert & Allen, 2002) and VA (Bradley et al., 2007) settings. The AUDIT-C includes the first three questions of the original 10-item AUDIT measure. Positive screenings (i.e., 3 out of 3 possible points) indicate problematic alcohol use and the need for more comprehensive assessment (e.g., clinical interview, additional instruments) to aid differential diagnosis. Question 3 of the AUDIT/AUDIT-C that addresses binge drinking (i.e., ≥ 4 drinks/occasion) has also been shown to be an effective single-item screening tool (see Bradley et al., 2003).

Screening of Postconcussive-Like Symptoms Some have identified traumatic brain injury (TBI) as a “signature” injury of the current conflicts in Iraq and Afghanistan (Hoge et  al., 2008). The vast majority (i.e., 80%–90%; see Donnelly et al., 2011) of these injuries are of mild severity (mTBI or concussion), and there has been concern that symptoms associated with mTBI may go undetected. Reports of mTBI (rarely confirmed by acute-stage injury records) are common (i.e., reported by 15%–20% of OEF/OIF veterans), and symptoms associated with self-reported mTBI have been found to be highly comorbid with numerous mental and physical health conditions (Belanger et  al., 2012; Donnelly et  al., 2011). In order to provide the best care for returning soldiers and veterans, the VA implemented the VA TBI screening tool (VATBIST), also known as the TBI clinical reminder, to assess for deployment-related TBI and residual postconcussive symptoms (Belanger et al., 2012; Donnelly et al., 2011). The VATBIST is a brief screening measure comprising four questions pertaining to events that may result in a TBI, potential loss/alteration of consciousness, acute injury postconcussive symptoms, and current postconcussive symptoms. Each question has numerous elements from which patients select to characterize their experience. Affirmative endorsement of at least one element within each of the four questions results in a positive screen; in contrast, denial of all elements within any one question results in a negative screen. Initial psychometric studies of the VATBIST have shown mixed results. The

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instrument has demonstrated adequate internal consistency (0.77; Donnelly et al., 2011); however, reliability has been variable, sensitivity has ranged from 60% to 94%, and specificity has ranged from 59% to 96% (see Belanger et  al., 2012). Reduced accuracy of the VATBIST has also been demonstrated in the context of significant PTSD symptoms (i.e., probable PTSD; Donnelly et al., 2011). Following a positive screen, veterans are referred for a more comprehensive, second-level TBI evaluation. As part of this evaluation, providers gather additional combat/medical history to determine whether a TBI was likely to have been sustained, and to further assess the etiology of an individual’s current symptom presentation. In addition, providers administer the Neurobehavioral Symptom Inventory (NSI; Cicerone & Kalmar, 1995), a reliable and valid self-report measure of postconcussive-like symptoms (King et al., 2012). The NSI includes 22 questions about physical, cognitive, and emotional/behavioral symptoms. The original NSI study (Cicerone  & Kalmar, 1995)  showed four distinct symptom clusters:  affective, cognitive, somatic, and sensory; however, a more recent study (Caplan et al., 2010)  showed a three-factor model of the NSI, including affective, cognitive, and somatic/sensory symptom groupings. The NSI was originally developed to provide a structure to postconcussive symptoms, though it has more recently been used to assess symptom severity. Several recent papers have raised concerns about the potential of the NSI to capture postconcussive symptom severity, primarily due to confounding PTSD symptoms (Benge et  al., 2009; Donnelly et  al., 2011; King et al., 2012). An additional limitation of the NSI is that it does not inform the provider of the link between the injury event and the onset of symptoms—information that is critical to confirming positive/negative TBI history (Betthauser et al., 2012). However, the NSI can be useful in assessing co-occurring psychiatric symptoms that may otherwise be interpreted as consistent with a history of TBI. Although the goal of the TBI screening and second-level evaluations is to cast a wide net in order to detect and treat all cases of TBI, some researchers have highlighted the potential iatrogenic effects of such an endeavor (Roth & Spencer, 2013; Vanderploeg  & Belanger, 2013). Roth and Spencer (2013) provided an illustrative case example of a veteran who underwent repeated neuropsychological evaluations, all of which attributed his cognitive symptoms to psychiatric disturbance as opposed to TBI sequelae. Despite these results, the veteran’s medical providers continued to attribute his symptoms to a history of TBI, leading the veteran to assume disability secondary to permanent brain damage. These authors highlight the need for education about the nature and trajectory of expected positive outcome from a single concussion in order to offset iatrogenic risk. Other researchers acknowledge the potential for iatrogenic risk but argue for the importance of early screening and intervention, regardless of etiology, to decrease military personnel and veteran burden of adversity (Brenner, Vanderploeg, & Terrio, 2009). Interventions should be evidence-based and inclusive of psychoeducation regarding the expected, favorable course of recovery following mTBI (Brenner, Vanderploeg, & Terrio, 2009). Researchers have consistently confirmed that PCS-like symptoms are highly nonspecific and are commonly observed in clinical and healthy community samples who have not sustained previous concussions. Various noninjury factors (e.g., premorbid psychiatric histories, postinjury stressors, secondary gain issues) have also been identified as significantly predictive of persisting PCS.

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Of potentially greater relevance to outpatient mental health settings, Belanger et al. (2013) demonstrated that certain “malleable” factors predict late-stage PCS. The authors found that knowledge of recovery outcomes, sense of self-efficacy, and level of attribution (i.e., belief that symptoms are directly reflective of previous mTBI) predicted 21% additional variance in overall symptom report above and beyond demographic factors and psychiatric symptom severity. Findings like these provide empirical support to interventions that promote psychoeducation regarding mTBI recovery outcomes and dismantling cognitive biases that may reinforce PCS. THE CLINICAL INTERVIEW Review of background information, including the results of screening instrumentation described above, allows the clinician to develop a general idea of a veteran’s presenting difficulties prior to the time of the initial meeting, and in turn to develop key questions to ask at the time of the initial clinical interview. The clinical interview serves several purposes that are fundamental to comprehensive psychological assessment. For example, responses to interview questions inform the degree to which an individual veteran is able (and willing) to represent his or her premorbid background, including but not limited to previous psychiatric history. Consistencies and inconsistencies noted between self-report information and information obtained through record review can assist the clinician’s ability to identify the veteran’s ability to represent background information accurately, and to identify potential motivations that may underlie minimization of previous histories (e.g., secondary gain issues, preference for medical as opposed to psychological explanations for ongoing difficulties). Moreover, the clinical interview allows for a more appropriate assessment of specific background issues that may not be fully elucidated through previous record review or formal psychometric assessment. Assessment of such issues as suicide risk and self-harm, for example, are better assessed through direct inquiry than exclusive reliance on record review or results of a self-report measure of psychological functioning. The clinical interview also allows the clinician to obtain a thorough medical history and to discover conditions that may bear upon issues of mental health—issues that may not have been identified through previous screening or record review. Here, we discuss general issues to consider during the interview phase of the psychological assessment, both through unstructured and structured approaches.

Unstructured Interview Practitioners vary widely regarding their approach to the clinical interview. Currently there are no specific standards set forth within the VA to guide practitioners in their collection of clinical information, and variable techniques or measures used often reflect differences in training background, experience, and setting. Nevertheless, most clinicians consistently obtain information relevant to general demographic information (e.g., sex, race/ethnicity, age, level of education), presenting concerns (emotional, physical, cognitive), personal medical and psychiatric history, family medical and psychiatric history, social/developmental history, military history, occupational history, and legal history.

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It is also important for the clinician to recognize that a range of co-occurring psychiatric and medical conditions is often the rule rather than the exception when working with this population, which creates great challenges for time-limited assessment. Specific to OEF/OIF veterans, literature by Hoge and colleagues (2008) examining the use of psychiatric screening tools demonstrated that returning soldiers are at high risk for PTSD (18%–20%), anxiety (16%–17%), depression (14%–15%), and increased alcohol use (20%–30%). When accounting for post-deployment functional impairment, prevalence rates for PTSD or depression with serious functional impairment ranged between 8.5% and 14.0%, whereas prevalence rates with some level of functional impairment ranged between 23.1% and 31.1%; alcohol use or aggressive behavior comorbidity was also present in half of these cases (Thomas et  al., 2010). As highlighted by Stecker et al. (2010), general epidemiological studies examining the comorbidity of these conditions have shown that PTSD often co-occurs with depression (48%–60%) and substance use disorders (34%–88%). In sum, across military eras, thorough assessment of the potential range of psychiatric comorbidities is essential. Context-specific factors (e.g., setting, symptoms) may also guide more in-depth questioning for certain categories, and certain assessment settings warrant a more comprehensive interview (e.g., Compensation and Pension [C  & P] evaluations). However, wide variation in interview and assessment approach is noted even within the C  & P assessment setting. A  recent survey of VA mental health professionals conducting PTSD C  & P evaluations showed that although 53% of these clinicians reported a preference for a standardized interview, 85% and 90% reported they “never” or “rarely” use the Clinician Administered PTSD Scale (CAPS; Blake et al., 1995) or the Structured Clinical Interview for DSM-IV Axis I Disorders (SCID; First et al., 1996), respectively (Jackson et  al., 2011). Remarkably, a majority (59%) of these clinicians reported “rarely” or “never” using formal psychometric testing to aid their diagnosis. These results demonstrated that the majority of respondents approach assessment in ways that are inconsistent with best practices emphasizing the use of a standardized diagnostic interview and psychometric instruments (Jackson et al., 2011).

Suicidality and Self-Harm Suicidality and risk of self-harm is a good example of an issue that is best assessed through close questioning during the clinical interview. Although scales have certainly been developed to assist the clinician to identify suicidality (e.g., MMPI-2 critical items; PAI SUI scale), the reality is that there is no substitute for a thorough discussion of an individual’s ideas surrounding the suicidal ideation, as well as any associated intention or plan of harming oneself. It has been argued that widespread screening of suicidality in veteran samples, if conducted outside the specialty care setting, will have very limited predictive utility with respect to future self-harm (Hoge & Castro, 2012). The clinical interview allows the clinician to assess for positive factors, such as level of social support, that have been identified as dramatically reducing the risk of self-harming behavior (Bossarte et al., 2012).

Medical History and Risk of Psychiatric Illness In addition to essential information related to veterans’ psychiatric history, the clinical interview allows the clinician to gain an understanding of veterans’ premorbid

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medical history, which may not have been available through review of available records. Persistent depression, for example, has been significantly associated with the presence of chronic medical conditions, such as diabetes, heart disease, and hypertension (Findley et al., 2011). Some researchers have found that major affective disorders, including depression and dysthymia, are associated with increased risk of mortality in veteran samples, even after adjusting for demographic factors, medical comorbidities, and use of substances, including alcohol and tobacco (Kinder et al., 2008). Hoerster et  al. (2012) reviewed data from the 2010 Behavioral Risk Factor Surveillance Survey to elucidate self-reported health outcomes among male veterans (n = 53,406), active duty service personnel (n = 2,144), National Guard/Reserve service members (n = 3,724), and civilians (n = 110,116). A primary finding reported by these authors was that in spite of their ready access to healthcare services, veterans reported poor overall health, with significantly higher rates of both medical (e.g., cardiovascular disease, arthritis, cancer) and psychiatric (e.g., depression, anxiety) conditions relative to civilian respondents. The authors perceived that veterans’ poor health behavior may have in part accounted for the health differences relative to civilians. For example, veterans were more likely to endorse current use of tobacco and alcohol abuse than the National Guard and civilian comparison groups. In a similar study, Lehavot et al. (2012) also found women veterans to report poorer general health and greater health risk behaviors, chronic health conditions, and mental health conditions (e.g., depressive disorder). Chwastiak et al. (2011) found that veterans with psychiatric diagnoses (schizophrenia, PTSD, and bipolar disorder in particular) showed significantly greater likelihoods of cardiovascular risks on the basis of poor health behaviors (e.g., tobacco use, limited exercise). In light of the high frequency of medical comorbidities among veterans with mental health difficulties (Yano et al., 2010) and their potential contribution to persisting psychological and emotional symptoms, clinical psychologists are encouraged to assess veterans’ medical histories with as much intricacy as their psychiatric histories.

Structured and Semi-structured Interviews A structured interview approach is considered the “gold standard” for certain clinical diagnoses (e.g., PTSD). The Structured Clinical Interview for DSM-IV-TR Axis I  Disorders (SCID; First, Spitzer, Gibbon,  & Williams, 2007)  is among the most widely used and accepted measures in both clinical and research settings. The SCID allows for assessment of all relevant Axis I (SCID-I) and Axis II (SCID-II) disorders. Depending on the complexity of the presenting symptoms, the SCID-I takes approximately 1–2 hours to complete, whereas the SCID-II can typically be completed in 30–60 minutes. Because of its widespread utility and excellent psychometric properties, it has been translated into several other languages. In general, it is considered to be a valid and reliable instrument, though it is not without limitations (e.g., valid administration typically requires extensive training). The CAPS (Blake et  al., 1995)  is a structured clinical interview based on DSM-IV criteria that allows the examiner to systematically evaluate symptoms of post-traumatic stress within the past month and lifetime periods. The CAPS is often regarded as a “gold standard” for formal PTSD diagnosis and has demonstrated

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established reliability and validity based on its concurrence with other diagnostic measures and stability of results over time (Weathers et al., 2001). SELF-REPORT MEASURES OF PERSONALITY AND EMOTIONAL FUNCTIONING Information obtained through results of screening instruments and the clinical interview are typically integrated with results of formal, objective measures of psychological and emotional functioning. As discussed, these measures vary with respect to duration of administration, research base, and overall effectiveness in establishing the plausibility, quality, and severity of various psychological and emotional difficulties.

Face-Valid Self-Report Measures of Emotional Functioning A multitude of brief, face-valid self-report measures of emotional functioning have been developed. In general, these measures allow for a rapid assessment of emotional symptoms that may confirm the overall severity of symptoms reported during the clinical interview. It should be noted, however, that these measures typically do not include established symptom validity scales, and the transparent and easily recognizable (i.e., “face-valid”) quality of test items that comprise these measures render them vulnerable to issues of response invalidity (e.g., potential minimization or exaggeration of symptoms). Two of the more commonly relied upon measures of depression and anxiety include the Beck Depression Inventory, 2nd edition (BDI-II; Beck et al., 1996) and the Beck Anxiety Inventory (BAI; Beck & Steer, 1993), respectively. The BDI-II includes 21 items rated on a 4-point (0 to 3) scale specifying the severity of that symptom over the past 2 weeks, resulting in a total score ranging from 0 to 63. Cutoff scores for the BDI-II are well-established, with the following interpretive ranges: 0–13 (minimal depression), 14–19 (mild depression), 20–28 (moderate depression), and 29–63 (severe depression). The BAI is similar to the BDI-II but assesses common anxiety symptoms. The BAI is also comprised of 21 items rated on a 4-point (0 to 3) scale denoting severity/intensity of each symptom over the past week, resulting in a total score ranging from 0 to 63. Scoring of the BAI indicates the following interpretive ranges: 0–7 (minimal anxiety), 8–15 (mild anxiety), 16–25 (moderate anxiety), and 26–63 (severe anxiety). In addition to the typical emotional/cognitive symptoms of anxiety (e.g., fear, nervousness), the BAI also includes numerous somatic responses to anxiety (e.g., difficulty breathing, numbness/tingling, dizziness); consequently, providers should take caution when interpreting BAI scores for patients with confounding chronic health conditions. Of note, although the BAI was developed to minimize its overlap with the BDI, moderate to high correlations have been observed between the BAI and BDI-II among psychiatric outpatients (r  =  0.66; Beck et  al., 1996). This finding is not uncommon between self-report anxiety and depression measures, and highlights their tendency to tap into negative affect commonly seen in both of these conditions (Stulz & Crits-Christoph, 2010). Therefore, these measures should only be used as a component of a more comprehensive evaluation that includes a diagnostic clinical

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interview assessing factors that differentiate anxiety and depression (e.g., physiological symptoms more closely linked with anxiety; cognitive and motivational symptoms more closely linked with depression; Stulz & Crits-Christoph, 2010).

Extended Personality Inventories MMPI, MMPI-2, MMPI-2-RF The MMPI instruments (MMPI,MMPI-2, and MMPI-2-RF) continue to be among the most widely used self-report measures of personality and psychopathology in the United States (Boccaccini & Brodsky, 1999; Camara, Nathan, & Puente, 2000; Lees-Haley, Smith, Williams, & Dunn, 1996). Therefore, it is not surprising that the MMPI instruments have been used for generations in the assessment of American veterans. Indeed, a mere year after the publication of the MMPI in 1944, the US Army issued two group forms of the MMPI for use with servicemen (Morton, 1948). The rapid dissemination of the MMPI outside the confines of the University of Minnesota’s hospital was due in no small part to the need for an efficient and effective means of evaluating soldiers during World War II and later for veterans who sought treatment for both medical and psychiatric conditions through the VA facilities across the United States. The widespread use of the MMPI in the VA during the late 1940s and 1950s provided the opportunity for researchers to use the rapidly accumulating clinical data from veterans treated in the VA to develop actuarial and configural models for the prediction of relevant clinical and diagnostic criteria. Using a configural or code type of interpretive strategy quickly became the standard for interpretation of the MMPI and MMPI-2 (Gilberstadt & Duker, 1965). Indeed, one of the first actuarial guides was developed using veteran samples (Gilberstadt & Duker, 1965). Code types developed from veteran samples by Gilberstadt and Duker (1965) remain in use today and are referenced liberally in contemporary MMPI-2 interpretive guides (Graham, 2011; Greene, 2010). Given the long-standing use of the MMPI/MMPI-2 in veteran populations, there is a vast literature on the effectiveness of the MMPI/MMPI-2 with veterans, particularly with respect to conditions with a high base rate within veteran populations, such as PTSD. For example, distinctive code types and empirically derived scales were developed to assist clinicians in identifying combat-related PTSD using the MMPI/MMPI-2 (Fairbank, Keane, & Malloy, 1983; Keane, Malloy, & Fairbank, 1984; Penk, Rierdan, Losardo, & Robinowitz, 2005). Moreover, samples from VA inpatient settings were used to develop and validate the Fp scale, a scale designed to identify noncredible or feigned report of psychiatric illness (Arbisi & Ben Porath, 1995; Arbisi & Ben Porath, 1998; Arbisi, Ben Porath, & McNulty, 2006). The Fp is now part of the standard scoring for the MMPI-2, and a revised version of the scale is included on the MMPI-2 Restructured Form (MMPI-2-RF). To improve the discriminant and convergent validity of the MMPI-2 Clinical Scales, Tellegen and colleagues developed a new set of scales by removing shared variance associated with demoralization from the clinical scales and identifying the remaining significant core component(s) of those scales (Tellegen et al., 2003). The resulting nine non-overlapping Restructured Clinical Scales (RC) demonstrated improved predictive and discriminant validity when compared to the original

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clinical scales (Tellegen et al., 2003; Tellegen et al., 2006). In validity studies specific to veteran populations, the RC scales were found to predict clinically relevant criteria in a wide range of veteran populations, including psychiatric outpatient and inpatient settings (Arbisi, Erbes, Polusny, & Nelson, 2010; Arbisi, Sellbom, & Ben Porath, 2008), VA outpatient primary care medical settings (Forbey, Ben-Porath, Arbisi, 2012), and VA substance abuse treatment programs (Forbey & Ben Porath, 2007; Forbey, Ben Porath, & Arbisi, 2012). Further, the RC scales were effective in identifying veterans with PTSD (Wolf et al., 2008; Arbisi, Polusny, Erbes, Thuras, & Reddy, 2011), as well as veterans who reported experiencing mild TBI and persistent symptoms when referred for neuropsychological evaluations (Nelson et al., 2011). Finally, RC 3 (Cynicism) predicted treatment engagement in combat-exposed veterans. Specifically, scores on RC 3 obtained prior to a prolonged combat deployment incrementally predicted failure to obtain needed mental health care in veterans who were diagnosed with either substance abuse/dependence, depressive disorders, or anxiety disorders including PTSD 2 years after returning from deployment (Arbisi, Rusch, Polusny, Thuras, & Erbes, 2013). Following the same strategy used to develop the RC scales, Ben-Porath and Tellegen (2008) constructed the MMPI-2 Restructured Form (MMPI-2-RF). The MMPI-2-RF is composed of 338 items drawn from the 567 MMPI-2 item pool and contains 51 new or revised scales. Noteworthy is the addition of new validity scales designed to specifically identify noncredible reporting of somatic symptoms and noncredible cognitive complaints. Importantly, the MMPI-2-RF is built around the RC scales, maintaining a bridge between the two instruments while providing a sufficiently broad banded assessment of psychological and emotional functioning. This was achieved by adopting a hierarchical interpretive approach through more narrow-band, specific-problem scales and higher order scales tied to contemporary theory of psychopathology (Ben Porath, 2012; Ben Porath & Tellegen, 2008). Research to date in veteran populations with the MMPI-2-RF has demonstrated the effectiveness of the new or revised validity scales in identifying noncredible reporting of PTSD and somatic symptoms. For example, the Fp-r scale effectively identified veterans who were instructed to exaggerate PTSD symptoms with low rates of false positive errors. Further, the Fs scale, designed to identify noncredible report of somatic symptoms, was effective in discriminating a group of veterans obtaining care through a VA outpatient primary care clinic who were instructed to feign a medical condition after an injury from those who accurately reported their physical symptoms (Sellbom, Wygant, & Bagby, 2012). With regard to the substantive scales on the MMPI-2-RF, the technical manual (Tellegen  & Ben-Porath, 2008)  provides validity coefficients for each RF scale in VA psychiatric inpatient samples, VA psychiatric and medical outpatient samples, and veterans undergoing substance abuse treatment in the VA. Additionally, mean scores on each of the MMPI-2-RF scales are reported in these veteran groups to assist in the interpretation of MMPI-2-RF protocols obtained from veteran populations. Although studies are limited with regard to findings using the stand-alone MMPI-2-RF in veterans due to delays in incorporating the computerized scoring of the RF in the VA electronic medical records system, early studies suggest that the MMPI-2-RF is able to distinguish between veterans returning from combat

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deployment to Iraq who screened positive for PTSD and those who did not (Arbisi et al., 2011).

Personality Assessment Inventory (PAI) The PAI is a self-report inventory consisting of 344 items using a 4-point Likert response format. The PAI yields 22 non-overlapping scales, including four scales designed to identify response bias (Morey, 2007). In contrast to the MMPI-2, there are relatively few published studies using the PAI in veteran populations, although the use of the PAI within the VA is expanding (Calhoun, Collie, Clancy, Braxton, & Beckham, 2010; Fuller, Lee, & Gordis, 1988). Specifically, the PAI has been used in the assessment of PTSD and alcohol dependence in veteran populations (Fuller et al., 1988; Mozley, Miller, Weathers, Beckham, & Feldman, 2005). With regard to detection of noncredible reporting of psychiatric symptoms and cognitive complaints, the PAI negative bias scales were unable to discriminate between veterans who failed symptom validity tests (SVT) and those who did not in veterans who reported mTBI and had been referred for neuropsychological assessment (Armistead-Jehle, 2010). In contrast, a malingering index derived from 8 PAI items was able to distinguish between a group of veterans diagnosed with PTSD and a group of undergraduates instructed to feign PTSD (Liljequist, Kinder, & Schinka, 1998). Finally, the PAI suicide scale was used to assess suicide in a study examining the relationship of PTSD, comorbid depression, and war era on suicidal ideation in veterans (Pukay-Martin et al., 2012). There is some indication that the PAI clinical scales show incremental value in assessing PTSD when used in conjunction with the MMPI-2, as in the case of women veterans with histories of sexual assault (Arbisi et al., 2010).

Millon Clinical Multiaxial Inventory-III (MCMI-III) The MCMI-III (Millon, Davis, & Millon, 1997) is a psychological assessment measure standardized specifically on clinical populations. An important distinction of the MCMI-III is that it is a criterion-referenced test, as it determines the probability that an individual has a certain diagnosis based on a cutoff score (relative to a clinical rather than a normative population). It is composed of 175 true-false questions, takes 25–30 minutes to complete, and requires at least an eighth grade reading level. The current version of the MCMI includes 14 personality scales and 10 clinical scales developed to reflect psychological constructs in the Diagnostic and Statistical Manual of Mental Disorders (DSM). Similar to other measures discussed, there are no known studies examining the use of the MCMI-III specifically with veterans, and more often studies are specific to the forensic context. The MCMI-III has received significant criticism in the literature regarding general validity and error rate concerns (Rogers, Salekin, & Sewell, 1999, 2000;), use of base rate score transformations that are not adjusted to reflect epidemiological rates (Grove & Vrieze, 2009), and the required high reading level (Bow, Flens, & Gould, 2010). Nonetheless, recent literature shows the MCMI-III is widely used, particularly in forensic settings. Results of a recent survey of forensic psychologists showed that 55% of respondents reported using the MCMI-III in forensic evaluations, and 40% believed that it required a ninth grade reading level (Bow, Flens,  & Gould,

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2010). Perhaps of greatest concern, this study revealed that only 51% of respondents used appropriate significance base-rate cutoffs (i.e., 75; Millon, Millon, Davis,  & Grossman, 2006, 2009) and evidenced over-reliance on computer-generated interpretive reports that also do not employ recommended cutoffs (Bow, Flens, & Gould, 2010). Consequently, over-diagnosis with use of the MCMI-III is a notable concern, even in settings that emphasize accuracy in “expert” testimony. PROJECTIVE METHODS

Rorschach Inkblot Method Given an extended, and sometimes unproductive, debate in the literature, clinicians may find it challenging to objectively evaluate the validity and clinical utility of projective instruments such as the Rorschach Inkblot Method (Rorschach, 1921/1942) or the Thematic Apperception Test (TAT; Murray, 1943). In fact, they may not be aware of a recent movement to relinquish the “projective” descriptor of these measures (e.g., Meyer & Kurtz, 2006). A distinction between objective (e.g., the MMPI-2 or PAI) and projective measures is problematic because it suggests that one is more scientific than the other. In reality, both types of tests are valid (and invalid) in specific contexts and are to a degree subjectively interpreted by examiners. An alternative and more descriptive classification that is preferred by contemporary assessment psychologists differentiates between self-report instruments and performance-based measures (e.g., see Meyer et al., 2001; Weiner & Greene, 2008). The former measures typically require examinees to describe their experiences and interests, whereas the latter measures require examinees to complete tasks that are set for them. The following section briefly describes the Rorschach, specifically focusing on an extended debate regarding the validity of the instrument and summary of research with veterans. Recent developments that resulted in the Rorschach Performance Assessment System (R-PAS; Meyer, Viglione, Mihura, Erard, & Erdberg, 2011) are also described. The interested reader is referred to a comprehensive text by Weiner and Greene (2008) for discussion of psychometric properties and clinical utility of other performance-based assessment tools, such as the TAT. The Rorschach has been described as both the “most cherished” and “most reviled” psychological instrument (Hunsley & Bailey, 1999). The literature contains compelling case examples that suggest that assessment with the Rorschach is beneficial (e.g., see Salley & Teiling, 1984) and harmful (Garb, Wood, Lilienfeld, & Nezworski, 2002). While the development of the Rorschach and various scoring systems is complex and interesting, we will primarily focus on Exner’s Comprehensive System (CS; Exner, 2003). In short, Exner reviewed existing literature and surveyed clinicians to select CS variables. Importantly, the CS provided a systematic approach to administration and coding, as well as normative data. The CS is the primary scoring system used by clinicians. In fact, a recent survey documented that nearly all clinicians (96%) who regularly use the Rorschach interpret the test using the CS as their primary system (Meyer, Hsiao, Viglione, Mihura, & Abraham, 2013). Additionally, while it is beyond the scope of this chapter to describe each CS score and related interpretations, Mihura, Meyer, Dumitrascu, and Bombel (2013) concisely provided variable definitions, example responses, and related interpretations. After

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discussing a relatively limited amount of literature describing use of the Rorschach with veterans, we address issues that are frequently debated in the literature regarding the validity and clinical utility of the Rorschach. These are not minor issues, as evidenced by the publication of numerous Special Sections in journals such as Psychological Assessment, Assessment, and the Journal of Clinical Psychology in recent years. Primary topics discussed in these articles are interrater reliability, validity of scores, and the appropriateness of CS norms. While our personal experience is that the Rorschach is used semi-regularly in select VA medical centers, there is a relatively small amount of published Rorschach research specific to veterans. In fact, a cursory PsycINFO literature search conducted on July 10, 2013, using the keywords Rorschach and veterans resulted in identification of only 22 documents. A great majority of these studies investigated how individuals with PTSD complete the Rorschach (Burch, 1993; Frueh, Leverett, & Kinder, 1995; Goldfinger, 1999; Gray, 2006; Hartman et  al., 1990; Sloan, Arsenault, Hilsenroth, Handler,  & Harvill, 1996; Sloan, Arsenault, Hilsenroth, Harvill,  & Handler, 1995; Souffront, 1987; Swanson, Blount, & Bruno, 1990). Consistent with expectation, Rorschach scores generally suggested that veterans with PTSD have difficulty controlling impulsivity and experience acute stress and intrusive thoughts. Further, relative to baseline data, Sloan and colleagues (1996) reported observing positive changes in Rorschach scores associated with stress responses after 3  years. While this body of literature is impressive and generally supports that Rorschach scores can differentiate individuals with PTSD from other groups, it is important to recognize that one study found that Rorschach scores produced by individuals with PTSD were not specific per se to PTSD, as combat and noncombat control groups obtained similar scores (Goldfinger, 1999). In summary, clinicians can be confident that there is an evidence base to support using the Rorschach with select veteran samples, including those with PTSD. Clinicians familiar with the Rorschach certainly recognize the unique challenges associated with scoring an individual’s responses. Significant concerns have been persistently raised regarding scoring reliability of the CS by a small group of researchers (e.g., see Garb et al., 2001, Wood & Lilienfeld, 1999; Wood, Nezworski, & Stejskal, 1996, 1997). For example, after reviewing a broad literature, Lilienfeld, Wood, and Garb (2000) suggested that only approximately half of the CS variables are reliably scored at a level suitable for clinical work. On the other hand, empirical data exist that suggest otherwise (Meyer, 1997a, 1997b). In fact, a thorough evaluation of interrater reliability making use of eight large samples documents excellent reliability between raters (Meyer et al., 2002). While it is beyond the scope of the current chapter to elaborate on methodological explanations for these differing opinions, it is clear that data do support that the Rorschach can be reliably scored by individuals familiar with the CS. Importantly, it is not a given that anyone who uses the CS is automatically reliable. Similar to instruments such as the Wechsler Adult Intelligence Scale, fourth edition (WAIS-IV, Wechsler, 2008), accurate Rorschach scoring requires extensive knowledge of administration rules and scoring procedures. There is also debate whether use of Exner’s (2003) CS norms will result in identification of psychopathology in relatively healthy functioning individuals. In support of this position, Shaffer, Erdberg, and Haroian (1999) evaluated nonpatient adults

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and obtained many scores that suggested the presence of psychopathology in relation to the CS normative sample. In a relatively focused meta-analysis, compared to CS norms, a subset of score indices were elevated in nonpatient adults across studies that would also suggest the presence of psychopathology (Wood, Nezworski, Garb,  & Lilienfeld, 2001). In contrast, a more comprehensive meta-analysis that included over 2,000 nonclinical patients and investigated a wider range of Rorschach scores (69 versus 14) suggests the presence of only minor score differences between nonclinical patients and CS norms (Meyer, 2001). While it is not clear that CS norms are problematic, Meyer (2001) suggested that revised scoring guidelines, data collection efforts, and/or meaningful changes in individuals over time may contribute to score differences observed between nonpatient samples. Encouragingly, Meyer, Erdberg, and Schaffer (2007) have presented a large-scale project that presents contemporary norms from the United States and many other countries that clinicians may consider utilizing during clinical assessment. A number of meta-analyses have been conducted to evaluate the validity of the Rorschach. Broadly, it has been repeatedly documented that the “global” validity of the Rorschach is generally in the medium range and is similar to that of the MMPI (e.g., see Atkinson, 1986; Hiller, Rosenthal, Bornstein, Berry,  & Brunell-Neuleib, 1999; Parker, Hanson, & Hunsley, 1988). A recent study by Mihura and colleagues (2013) systematically reviewed the validity of individual Rorschach variables and clearly described the magnitude of empirical research supporting each variable. While this meta-analytic review was conducted by researchers who typically support use of the Rorschach, the presentation of results is balanced and clarifies both the strengths and limitations of the instrument. As an example, Mihura and colleagues reported strong to good validity (r  ≥.21) for variables associated with cognitive and perceptual processes (e.g., Perceptual-Thinking Index, Critical Special Scores, Distorted Form), impulsive or dangerous behaviors (e.g., Suicide Constellation, Form-Color Ratio), and psychological resources and cognitive complexity (e.g., Human Movement, Experience Actual, Lambda). On the other hand, the authors acknowledged that 25 of 65 CS variables have either never been evaluated or exhibit low, unstable, or non-significant levels of validity. While it is difficult to concisely describe what psychological constructs these variables are associated with, the responses typically have extremely low base rates, which complicates subsequent research efforts. Clinicians who regularly administer the Rorschach, or are considering the instrument, are encouraged to review Mihura et al. (2013) to guide interpretation and case conceptualization. While there is objective support for a number of Rorschach variables, there is also compelling evidence that Rorschach data incrementally improves prediction of certain behaviors (Meyer & Viglione, 2008; Viglione & Hilsenroth, 2001). For example, multiple studies have documented that prediction of psychotic disorders is improved when Rorschach variables are added to relevant MMPI scales (Dao, Prevatt, & Horne, 2008; Meyer, 2000a; Ritsher, 2004). It has also been documented that Rorschach scores assessing functional capacity can predict subsequent outcome over intelligence and the MMPI Ego Strength scale (Meyer, 2000b). This body of literature suggests that clinicians should not expect information obtained from the Rorschach and self-report measures to directly correspond with one another.

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More important, the scores augment one another, and this literature makes clear why multimodal assessment is beneficial in accurately identifying psychological issues. Historically, the Rorschach has been administered, scored, and interpreted in different ways. While the CS system was notable in emphasizing standardized administration and empirically supported variables, it is not without limitation. Recent efforts to capitalize on empirical Rorschach findings resulted in publication of the Rorschach Performance Assessment System (R-PAS; Meyer et al., 2001). The R-PAS provides clearer and more detailed guidelines for test administration. For example, revised administration procedures result in all patients providing a more similar number of responses (typically 18 to 28), which improves interpretation of data. Relative to the CS, some scoring variables were added, excluded, or reconfigured, based upon empirical literature (e.g., Mihura et al., 2013). In summary, the R-PAS was developed to make the Rorschach more approachable to both new and experienced clinicians. It is expected that this broad reformulation of the test will facilitate increased reliability, validity, and utility. COGNITIVE MEASURES Here, we provide a brief summary of select measures that general practitioners might consider to establish a general overview of a veteran’s intellectual and cognitive abilities, as well as basic screening measures that might be considered when there is concern regarding impairments that might warrant a more comprehensive neuropsychological evaluation. Interested readers are referred to other seminal works (Lezak et al., 2012; Strauss, Sherman, & Spreen, 2006) for a more complete review of common measures administered in the clinical neuropsychological evaluation setting.

Wechsler Adult Intelligence Scale, Fourth Edition (WAIS-IV) The WAIS and its revisions are among the most frequently relied upon measures of intellectual and cognitive functioning among clinical psychologists and neuropsychologists. The fourth edition of the WAIS (Wechsler, 2008) includes subtests that assess cognitive abilities in the areas of verbal comprehension, perceptual reasoning, working memory, and processing speed abilities, with performances resulting in an overall composite of intellectual ability. The WAIS-IV allows the clinician to obtain rich information related to these various areas of cognitive function in a relatively brief span of time (90 to 120 minutes). Incidentally, it has been our experience that many clinical psychologists and neuropsychologists continue to make use of the third edition of the WAIS (WAIS-III). Indeed, some have questioned whether there is sufficient evidence that the shift from the WAIS-III to WAIS-IV is warranted on an empirical basis (cf., Loring & Bauer, 2010; Russell, 2010). Ultimately, there is no well-established consensus as to when it is “time” to transition from one published instrument to the next (Bush, 2010), and the decision to “make the switch” is left to the discretion of the individual clinician in review of the American Psychological Association (2010) Ethics Code on issues related to use of “obsolete” tests (see Standard 9.08b).

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Brief Screening Instruments The Mini-Mental State Examination (MMSE; Folstein, Folstein,  & McHugh, 1975) and its more recent revision (Folstein, Folstein, McHugh, & Fanjiang, 2010; MMSE-2) are very brief measures of orientation and cognitive screening that are often administered in medical settings, particularly among aging individuals who may show early signs of Alzheimer’s disease or other form of neurodegenerative dementia. The task allows the clinician to assess basic domains of orientation, attention, language, visual-spatial, and executive functioning in a short period of time (i.e., 5 to 10 minutes at most). As with any cognitive screening instrument, the MMSE is most likely to identify fairly severe cognitive impairments (e.g., as in the case of advanced Alzheimer’s dementia), but is likely to result in false negative identifications of cognitive limitation among those who may experience limitations earlier in the disease course or who present with more subtle signs of impairment. Nevertheless, to the extent that an aging veteran (and/or his or her family) express concern about cognitive changes, diminished MMSE performance would clearly warrant a referral for a more comprehensive neuropsychological evaluation to further inform the quality and severity of impairment, potential causes, and relevance to everyday functions. Another example of a brief cognitive screening instrument is the Montreal Cognitive Assessment (MoCA; Nasreddine et al., 2005), which has been translated in a variety of languages and includes cognitive tasks (e.g., set-shifting) that may be more sensitive to executive difficulties that are not assessed by the MMSE or MMSE-2. The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 1998) is a more comprehensive screening measure that consists of 12 subtests that evaluate multiple cognitive constructs. A majority of the subtests are revised versions of classic neuropsychological tests and contribute to Immediate Memory, Visuospatial/Constructional, Language, Attention, and Delayed Memory Index scores. Not surprisingly, RBANS subtests are meaningfully related to conceptually similar tasks. For example, Randolph reported that the RBANS List Learning subtest is highly correlated with well-validated memory tests. Overall, Randolph reported that the instrument has strong psychometric properties; however, it is notable that factor analytic studies have most commonly resulted in a two-factor structure (e.g., see Duff et al., 2006; Wilde, 2006), as opposed to an underlying structure that is consistent with the Index structure. While the RBANS was developed to function as a stand-alone battery for efficiently and effectively identifying dementia in older adults, subsequent research has documented that it is useful in a wide range of clinical contexts, such as stroke (Larson, Kirschener, Bode, Heineman, & Goodman, 2005), schizophrenia (Holzer et al., 2007), and Parkinson’s disease (Beatty, Ryder, Gontkovsky, Scott, McSwan, & Bharucha, 2003). There is additionally a body of research that supports the use of the RBANS as a clinically valid and reliable measure that can be used with individuals who sustain a moderate or severe traumatic brain injury (e.g., see McKay, Casey, Wertheimer, & Fichtenberg, 2007). Further, Lippa, Hawes, Jokic, and Caroselli (2013) reported that the RBANS is useful in assessing cognitive functioning in acute TBI settings. Specifically, the Delayed Memory Index and Total Score were significantly predicted by post-traumatic amnesia. A unique feature relative to many neuropsychological measures, RBANS tasks are available in alternative versions that make the

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instrument especially useful in situations where serial evaluation is warranted (e.g., pre- and post-surgical evaluation).

DSM-IV-TR and DSM-5 We conclude with a brief discussion of recent developments in the use of diagnostic criteria to support formal psychological diagnoses, issues that are directly relevant to psychological assessment in any outpatient mental health setting. The fourth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV; American Psychiatric Association, 1994)  and the text revision (DSM-IV-TR; American Psychiatric Association, 2000)  largely defined the psychological assessment practices of mental health providers for the better portion of the last two decades. The DSM-IV-TR has also represented a “gold standard” for innumerable research samples, culminating in a wealth of empirical data relevant to issues of etiology, best practices in treatment, and prognosis of varied mental health disorders. As such, it is not surprising that the May 2013 release of the DSM-5 (American Psychiatric Assocation, 2013) has been surrounded by controversy, particularly in light of the changes that have been made, which are in some instances fairly substantial. An extended review of DSM-IV-TR and DSM-5 similarities and differences across conditions far transcends the scope of this chapter, and the reader is encouraged to develop a more comprehensive working knowledge of DSM-IV-TR/DSM-5 changes. However, as one illustration, consider the modifications made to the diagnosis of PTSD within DSM-5 (see Table 2.1). The most striking modification relates to a lowered threshold to fulfill criterion A  (the trauma event itself). DSM-IV-TR required not only exposure to a plausible traumatic event (A1), but the exposure was necessarily followed by a specific response of intense fear, helplessness, or horror. By contrast, in DSM-5, criterion A requires exposure to a traumatic event only and does not include a specific behavioral, cognitive, or emotional response. DSM-5 criterion A  also affords a broader definition of what constitutes a plausible traumatogenic event, including vicarious trauma exposure (e.g., learning of a traumatic event experienced by a close family member or friend; A3). Those who experience repeated or extreme exposure to “aversive details of the traumatic event(s)” (e.g., police officers who are repeatedly exposed to details of child abuse) may also meet criterion A, though the manual clarifies that A4 does not apply to exposure through public media (e.g., television, films) unless that exposure is “work related.” The manual further clarifies that while indirect exposure to the traumas of others may fulfill criteria for a traumatic event, these indirect exposures are limited to experiences that affect close relatives or friends, and these events must be violent or the result of an accident (e.g., suicide, assault, serious injury). Death of a family member due to natural causes, for example, would not qualify as a traumatic event. According to the DSM-5 (p. 274), “a life-threatening illness or debilitating medical condition is not necessarily considered a traumatic event.” However, certain medical incidents (e.g., waking during surgery) may be construed as plausible traumatic events, as can medical catastrophes sustained on the part of one’s child (e.g., life-threatening hemorrhage). DSM-5 Criterion B places slightly greater emphasis on dissociation (B3). DSM-5 Criterion C retains avoidance symptoms, and other DSM-IV-TR Criterion

Table 2.1.  Comparison of DSM-IV-TR and DSM-5 Diagnostic Criteria of Post-Traumatic Stress Disorder (PTSD) DSM-IV-TR Criteria Criterion A A1: experienced, witnessed trauma (Trauma events; and Exposure) A2: response of intense fear, helplessness, horror

DSM-5 Criteria Criterion A (Trauma Exposure; 1 or more)

Criterion B B1: Recurrent, intrusive (Re-experience; recollections 1 or more) B2: Recurrent distressing dreams B3: Acting/feeling as if event recurring B4: Intense distress with cues B5: Physiological reactivity

Criterion B (Intrusions; 1 or more)

Criterion C (Avoidance/ Numbing; 3 or more)

Criterion C (Avoidance; 1 or 2)

C1-C2: Avoid thoughts, feelings, activities, places C3: Inability to recall trauma C4: Diminished interests C5: Detachment/estrangement C6: Restricted range of affect C7: Foreshortened future

Key DSM-5 Changes Broadened definition of vicarious trauma (A3); no longer required to respond with intense fear, helplessness, horror

A1: Directly witness trauma event A2: Witnessing event of others A3: Learning of trauma of close family or friend A4: Experiencing repeat or extreme exposure to aversive details of trauma event(s) B1: Recurrent, involuntary, intrusive Slightly greater emphasis on memories of the trauma dissociation (B3) B2: Recurrent distressing dreams (content and/or affect related to trauma) B3: Dissociative reactions (e.g., flashbacks) B4: Intense/prolonged distress at exposure to cues B5: Marked physiologic reactions to cues C1: Avoidance/efforts to avoid DSM-5 Criterion C retains avoidance distressing memories, thoughts, symptoms; other DSM-IV-TR C feelings symptoms (e.g., inability to recall; C2: Avoidance/efforts to avoid diminished interest) appear in external reminders that arouse DSM-5 Criterion D distressing memories, thoughts, feelings associated with the trauma event(s)

(continued)

Table 2.1. Continued DSM-IV-TR Criteria Criterion D D1: Sleep difficulty (Persistent D2: Irritability, anger Increased D3: Difficulty concentrating Arousal; 2 or D4: Hypervigilance more) D5: Exaggerated startle

DSM-5 Criteria Criterion D (Negative alterations in cognitions and mood; 2 or more)

Criterion E (Duration)

Criterion E (Alterations in arousal/ reactivity; 2 or more)

Duration of the disturbance (symptoms associated with Criteria B, C, D) more than 1 month

Key DSM-5 Changes D1: Inability to remember important DSM-5 Criterion D includes several aspect of trauma (not due to drugs/TBI) DSM-IV-TR Criterion C symptoms D2: Persistent, exaggerated negative (e.g., inability to recall; diminished beliefs/expectations about oneself, interest; feelings of detachment/ others, or world estrangement) D3: Persistent, distorted cognitions about cause/consequences of the trauma causing one to blame self or other D4: Persistent negative emotional state D5:Diminished interests/participation in activities D6: Feel detachment/estrangement from others D7: Persistent inability to feel positive emotion E1:Irritable behavior; angry outbursts DSM-5 Criterion E subsumes most of E2: Reckless or self-destructive behavior DSM-IV-TR Criterion D, and adds E3-4:Hypervigilance; exaggerated reckless, self-destructive behavior startle response E5: Concentration problems E6: Sleep disturbance

DSM-IV-TR Criteria Criterion F Disturbance causes significant (Distress/ distress/impairment in social, Impairment) occupational, other functioning

DSM-5 Criteria Criterion F (Duration)

Key DSM-5 Changes Duration of the disturbance (Criteria Largely unchanged from DSM-IV-TR B, C, D, E) is more than 1 month Criterion E

Criterion G (Distress/ Impairment)

Specify if: Specify if: Specify if:

The disturbance causes clinically Largely unchanged from DSM-IV-TR significant distress or impairment Criterion F in social, occupational, or other important areas of functioning Criterion H The disturbance is not attributable New to DSM-5 (Physiological to the physiological effects of a Exclusion) substances (e.g., medication, alcohol) or another medical condition Specify whether 1. Depersonalization New to DSM-5 with dissociative 2. Derealization symptoms Acute (< 3 months) n/a n/a DSM-5 does not include acute/chronic specifiers Chronic (> 3 months) n/a n/a DSM-5 does not include acute/chronic specifiers Delayed (> 6 months post stressor) Specify if: With “delayed expression” (if full Largely unchanged, though “delayed diagnostic criteria not met until at onset” is “delayed expression” in least 6 months) DSM-5

Note: The above DSM-5 criteria are to be applied to adults, adolescents, and children older than 6 years. Alternate diagnostic criteria (not shown here) have been developed for children younger than 6 years.

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C symptoms (e.g., inability to recall, diminished interest, feelings of detachment/ estrangement) appear in DSM-5 Criterion D. DSM-5 Criterion E subsumes most of DSM-IV-TR Criterion D symptoms, and adds reckless and self-destructive behavior. Criterion F of DSM-5 (duration) retains the DSM-IV-TR Criterion E requirement that symptoms persist for more than one month. DSM-5 Criterion G, like DSM-IV-TR Criterion F, requires that the disturbance causes significant impairment in important areas of functioning. New to DSM-5 is Criterion H, which indicates that the disturbance is not attributable to the physiological effects of a substance (e.g., alcohol, medication), as well as a dissociative symptoms (depersonalization, derealization) specifier. Unlike DSM-IV-TR, DSM-5 does not include “acute” or “chronic” specifiers, and while there is a specifier included for late-stage symptom development, DSM-5 describes this as “delayed expression” rather than “delayed onset” if symptoms develop 6 months after the time of trauma exposure. Clearly, changes like these are significant enough to have implications for clinicians, researchers, and policymakers alike. At the time of the current writing, it is not yet clear whether and to what extent DSM-5 will be adopted within the VA system of care (or in civilian outpatient mental health settings). Nevertheless, the reality is that DSM-5 is here to stay, and a working knowledge of DSM-5 revisions will likely benefit the practices of outpatient mental health providers in one way or another (e.g., review of others’ use of DSM-5, if not their own). REFERENCES American Psychiatric Association. (1994). Diagnostic And Statistical Manual Of Mental Disorders (4th ed). American Psychiatric Association: Washington, D.C. American Psychiatric Association. (2000). Diagnostic And Statistical Manual Of Mental Disorders-Text Revision (4th ed). American Psychiatric Association: Washington, D.C. American Psychiatric Association. (2013). Diagnostic And Statistical Manual Of Mental Disorders (5th ed). American Psychiatric Association: Washington, D.C. American Psychological Association. (2010). Ethical principles of psychologists and code of conduct: 2010 amendments. Retrieved February 17, 2011, from www.apa.org/ethics/code/index.aspx Arbisi, P. A., & Ben Porath, Y. S. (1995). An MMPI-2 infrequent reponse scale for use with psychopathological poulations:  The Infrequency-Psychopathology Scale (Fp). Psychological Assessement, 7, 424–431. Arbisi, P. A., & Ben Porath, Y. S. (1998). The ability of Minnesota Multiphasic Personality Inventory-2 validity scales to detect fake-bad responses in psychiatric-inpatients. Psychological Assessment, 10, 221–228. Arbisi, P. A., Ben Porath, Y. S., & McNulty, J. (2006). The ability of the MMPI-2 to detect feigned PTSD within the context of compensation seeking. Psychological Services, 3, 249–261. Arbisi, P. A., Erbes, C. R., Polusny, M. A., & Nelson, N. W. (2010). The concurrent and incremental validity of the Trauma Symptom Inventory in women reporting histories of sexual maltreatment. Assessment, 17, 406–418. Arbisi, P. A., Kaler, M. E., Kehle-Forbes, S. M., Erbes, C. R., Polusny, M. A., & Thuras, P. (2012). The predictive validity of the PTSD Checklist in a nonclinical sample of combat-exposed National Guard troops. Psychological Assessment, 24(4), 1034–1040.

Outpatient Mental Health Settings

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Arbisi, P. A., Polusny, M. A., Erbes, C. R., Thuras, P., & Reddy, M. K. (2011). The Minnesota Multiphasic Personality Inventory 2 Restructured Form in National Guard soldiers screening positive for posttraumtic stress disorder and mild traumatic brain injury. Psychological Assessment, 23, 203–214. Arbisi, P.  A., Rusch, L., Polusny, M.  A., Thuras, P.  A.,  & Erbes, C.  R. (in press). Does cynicism play a role in failure to obtain needed care? Mental health service utilization among returning U.S. National Guard soldiers. Psychological Assessement. Arbisi, P.  A., Sellbom, M.,  & Ben Porath, Y.  S. (2008). Empirical correlates of the MMPI-2 Restructured Clinical Scales in psychiatric inpatients. Journal of Personality Assessment, 90, 122–128. Armistead-Jehle, P. (2010). Symptom validity test performance in U.S. veterans referred for evaluation of mild TBI. Applied Neuropsychology, 17, 52–59. Atkinson, L. (1986). The comparative validities of the Rorschach and MMPI:  A meta-analysis. Canadian Psychology/Psychologie canadienne, 27, 238–247. Beatty, W. W., Ryder, K. A., Gontkovsky, S. T., Scott, J. G., McSwan, K. L., & Bharucha, K.  J. (2003). Analyzing the subcortical dementia syndrome of Parkinson’s disease using the RBANS. Archives of Clinical Neuropsychology, 18(5), 509–520. Beck, A. T., & Steer, R. A. (1993). Manual for the Beck Anxiety Inventory. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., Ball, R., & Ranieri, W. F. (1996). Comparison of Beck Depression Inventories-IA and -II in psychiatric outpatients. Journal of Personality Assessment, 67(3), 588–597. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Beck Depression Inventory Manual (2nd ed.). San Antonio, TX: Psychological Corporation. Belanger, H. G., Barwick, F. H., Kip, K. E., Kretzmer, T., & Vanderploeg, R. D. (2013). Postconcussive symptom complaints and potentially malleable positive predictors. The Clinical Neuropsychologist, 27, 343–355. Belanger, H.  G., Vanderploeg, R.  D., Soble, J.  R., Richardson, M.,  & Groer, S. (2012). Validity of the Veterans Health Administration’s Traumatic Brain Injury Screen. Archives of Physical Medicine Rehabilitation, 93, 1234–1239. Ben Porath, Y.  S. (2012). Interpreting the MMPI 2 RF. Minneapolis:  University of Minnesota Press. Ben Porath, Y.  S.,  & Tellegen, A. (2008). MMPI-2-RF (Minnesota Multiphasic Personality Inventory-2 Restuctured Form) Manual. Minneapolis:  University of Minnesota Press. Benge, J. F., Pastorek, N. J., & Thornton, G. M. (2009). Postconcussive symptoms in OEF– OIF veterans:  Factor structure and impact of posttraumatic stress. Rehabilitation Psychology, 54(3), 270. Betthauser, L. M., Bahraini, N., Krengel, M. H., & Brenner, L. A. (2012). Self-report measures to identify post traumatic stress disorder and/or mild traumatic brain injury and associated symptoms in military veterans of Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF). Neuropsychology Review, 22(1), 35–53. Binder, L.  M.,  & Campbell, K.  A. (2004). Medically unexplained symptoms and neuropsychological assessment. Journal of Clinical and Experimental Neuropsychology, 26(3), 369–392. Blake, D.  D., Weathers, F.  W., Nagy, L.  M., Kaloupek, D.  G., Gusman, F.  D., Charney, D. S., & Keane, T. M. (1995). The development of a clinician administered PTSD scale. Journal of Traumatic Stress, 8, 75–90. doi:10.1007/BF02105408

42

P sychological A ss e ssm e nt of V e t e rans

Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD Checklist (PCL). Behaviour Research and Therapy, 34(8), 669–673. Boccaccini, M. T., & Brodsky, S. L. (1999). Diagnositic test usage by forensic psychologists in emotional injury cases. Professional Psychology: Reseach and Practice, 30, 253–259. Bohnert, A. S., Ilgen, M. A., Bossarte, R. M., Britton, P. C., Chermack, S. T., & Blow, F. C. (2012). Veteran status and alcohol use in men in the United States. Military Medicine, 177, 198–203. Bossarte, R. M., Knox, K. L, Piegari, R., Alteri, J., Kemp, J., & Katz, I. R. (2012). Prevalence and chracteristics of suicide ideation and attempts among active military and veteran participants in a national health survey. American Journal of Public Health, 102(S1), S38–S40. Bow, J. N., Flens, J. R., & Gould, J. W. (2010). MMPI-2 and MCMI-III in forensic evaluations: A survey of psychologists. Journal of Forensic Psychology Practice, 10(1), 37–52. Bradley, K.  A., DeBenedetti, A.  F., Volk, R.  J., Williams, E.  C., Frank, D.,  & Kivlahan, D.  R. (2007). AUDIT-C as a brief screen for alcohol misuse in primary care. Alcoholism: Clinical and Experimental Research, 31(7), 1208–1217. Bradley, K. A., Bush, K. R., Epler, A. J., Dobie, D. J., Davis, T. M., Sporleder, J. L., . . . & Kivlahan, D.  R. (2003). Two brief alcohol-screening tests from the Alcohol Use Disorders Identification Test (AUDIT): Validation in a female Veterans Affairs patient population. Archives of Internal Medicine, 163(7), 821. Brenner, L. A., Vanderploeg, R. D., & Terrio, H. (2009). Assessment and diagnosis of mild traumatic brain injury, posttraumatic stress disorder, and other polytrauma conditions: Burden of adversity hypothesis. Rehabilitation Psychology, 54(3), 239. Burch, R.  F. (1993). Assessment of post-traumatic stress disorder among Vietnam combat veterans: A Rorschach study. Dissertation Abstracts International, 54(5-B), 2742. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=reference&D=psy c3&NEWS=N&AN=1995-74728-001 Bush, K., Kivlahan, D.  R., McDonell, M.  B., Fihn, S.  D.,  & Bradley, K.  A. (1998). The AUDIT alcohol consumption questions (AUDIT-C): An effective brief screening test for problem drinking. Archives of Internal Medicine, 158(16), 1789. Bush, S. S. (2010). Determining whether or when to adopt new versions of psychological and neuropsychological tests. The Clinical Neuropsychologist, 24, 7–16. Calhoun, P. S., Collie, C. F., Clancy, C. P., Braxton, L. E., & Beckham, J. C. (2010). Use of the PAI in assessment of posttraumatic stress disorder among help-seeking veterans. In M. A.  Blias, M. R.  Baity,  & C. J.  Hopwood (Eds.), Clinical applications of the Personality Assessment Inventory (pp. 99–112). New York, NY: Routledge Taylor & Francis Group. Camara, W. J., Nathan, J. S., & Puente, A. E. (2000). Psychological test usage: Implications in professional psychology. Professional Psychology: Research and Practice, 31, 141–154. Caplan, L. J., Ivins, B., Poole, J. H., Vanderploeg, R. D., Jaffee, M. S., & Schwab, K. (2010). The structure of postconcussive symptoms in 3 US military samples. The Journal of Head Trauma Rehabilitation, 25(6), 447–458. Carlson, K. F., Gravely, A. A., Noorbaloochi, S., Simon, A. B., Bangerter, A. K., & Sayer, N.  A. (2011). Post-deployment injury among new combat veterans enrolled in Veterans Affairs (VA) healthcare. Injury Prevention, 17, 343–347. Chavez, L. J., Williams, E. C., Lapham, G., & Bradley, K. A. (2012). Association between alcohol screening scores and alcohol-related risks among female veterans affairs patients. Journal of Studies on Alcohol and Drugs, 73, 391–400.

Outpatient Mental Health Settings

43

Chwastiak, L. A., Rosenheck, R. A., & Kazis, L. E. (2011). Association of psychiatric illness and obesity, physical inactivity, and smoking among a national sample of veterans. Psychosomatics, 52, 230–236. Chwastiak, L. A., Rosenheck, R. A., Desia, R., & Kazis, L. E. (2010). Association of psychiatric illness and all-cause mortality in the national Department of Veterans Affairs Health Care System. Psychosomatic Medicine, 72, 817–822. Cicerone, K. D., & Kalmar, K. (1995). Persistent postconcussion syndrome: The structure of subjective complaints after mild traumatic brain injury. The Journal of Head Trauma Rehabilitation, 10(3), 1–17. Dao, T.  K., Prevatt, F.,  & Horne, H.  L. (2008). Differentiating psychotic patients from nonpsychotic patients with the MMPI-2 and Rorschach. Journal of Personality Assessment, 90, 93–101. Dichter, M. E., Cerulli, C., Bossarte, R. M. (2012). Intimate partner violence victimization among women veterans and associated heart health risks. Women’s Health Issues, 21, S190–S194. Donnelly, K. T., Donnelly, J. P., Dunnam, M., Warner, G. C., Kittleson, C. J., . . . & Alt, M. (2011). Reliability, sensitivity, and specificity of the VA traumatic brain injury screening tool. The Journal of head trauma rehabilitation, 26(6), 439–453. Duff, K.  D., Langbehn, D.  R., Schoenberg, M.  R., Moser, D.  J., Baade, L.  E., Mold, J. W., . . . & Adams, R. L. (2006). Examining the Repeatable Battery for the Assessment of Neuropsychological Status:  Factor analytic studies in an elderly sample. The American Journal of Geriatric Psychiatry, 14(11), 976–979. Elhai, J. D., Gray, M. J., Kashdan, T. B., & Franklin, C. L. (2005). Which instruments are most commonly used to assess traumatic event exposure and posttraumatic effects? A survey of traumatic stress professionals. Journal of Traumatic Stress, 18, 541–545. Erbes, C.  R., Meis, L.  A.,  & Polusny, M.  A. (2011). Couple adjustment and posttraumatic stress disorder symptoms in National Guard veterans of the Iraq War. Journal of Family Psychology, 25, 479–487. Exner, J. E. (2003). The Rorschach: A comprehensive system. Vol. 1: Basic foundations (4th ed.). Hoboken, NJ: Wiley. Fairbank, J. A., Keane, T. M., & Malloy, P. F. (1983). Some preliminary data on the psychological characteristics of vietnam veterans with posttraumatic stress disorders. Journal of Consulting and Clinical Psychology, 51, 912–919. Findley, P., Shen, C., & Sambamoorthi, U. (2011). Multimorbidity and persistent depression among veterans with diabetes, heart disease, and hypertension. Health & Social Work, 36, 109–119. First, M.  B., Spitzer, R.  L., Gibbon, M.,  & Williams, J.  B. (1996). Structured Clinical Interview for DSM-IV Axis I  Disorders, Clinical Version (SCID-CV). Washington, DC: American Psychiatric Press. First, M. B., Spitzer, R. L., Gibbon, M., & Williams, J. B. W. (2007). Structured clinical interview for DSM-IV axis I  disorders-clinician version (SCID-CV), 1997. American Psychiatric Association Press, Washington, DC. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12(3), 189–198. Folstein, M. F., Folstein, S. E., McHugh, P. R., & Fanjiang, G. (2010). Mini-mental state examination: MMSE-2. Psychological Assessment Resources. Forbey, J. D., & Ben Porath, Y. S. (2007). A comparison of the MMPI-2 restructured clinical (RC) scales in a substance abuse treatment sample. Psychological Services, 4, 46–58.

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Forbey, J. D., Ben Porath, Y. S., & Arbisi, P. A. (2012). The MMPI-2 Computer Adaptive Version (MMPI-2 CA) in a medical outpatient facility. Psychological Assessement, 24, 628–639. Freedy, J. R., Magruder, K. M., Mainous, A. G., Frueh, B. C., Geesey, M. E., & Carnemolla, M. (2010). Gender differences in traumatic event exposure and mental health among veteran primary care patients. Military Medicine, 175, 750–758. Frueh, B. C., Leverett, J. P., & Kinder, B. N. (1995). Interrelationship between MMPI-2 and Rorschach variables in a sample of Vietnam veterans with PTSD. Journal of Personality Assessment, 64, 312–318. Fuller, L.  K., Lee, K.  K.,  & Gordis, E. (1988). Validity of self-report in alcoholism research: Results of a Veterans Administration cooperative study. Alcoholism: Clinical and Experimental Research, 12, 201–205. Gadermann, A.  M., Engel, C.  C., Naifeh, J.  A., Nock, M.  K., Petukhova, M., Santiago, P. N., . . . & Kessler, R. C. (2012). Prevalence of DSM-IV major depression among US military personnel: meta-analysis and simulation. Military Medicine, 177(8S), 47–59. Garb, H. N., Wood, J. M., Lilienfeld, S. O., & Nezworski, M. T. (2002). Effective use of projective techniques in clinical practice: Let the data help with selection and interpretation. Professional Psychology: Research and Practice, 33, 454–463. Garb, H. N., Wood, J. M., Nezworski, M. T., Grove, W. M., & Stejskal, W. J. (2001). Towards a resolution of the Rorschach controversy. Psychological Assessment, 13, 433–448. Gates, M. A., Holowka, D. W., Vasterling, J. J., Keane, T. M., Marx, B. P., & Rosen, R. C. (2012). Posttraumatic stress disorder in veterans and military personnel: Epidemiology, screening, and case recognition. Psychological Services, 9(4), 361–382. Gilberstadt, H., & Duker, J. (1965). A handbook for clinical and actuarial MMPI interpretation. Philadelphia. PA: Saunders. Goldfinger, D.  A. (1999). Rorschach patterns in Vietnam veterans with post-traumatic stress disorder:  A  study of cognition, psychophysiology, and psychological defense. Dissertation Abstracts International:  Section B:  The Sciences and Engineering, 59(7-B), 3691. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE=ref erence&D=psyc3&NEWS=N&AN=1999-95002-254 Goodwin, B. E., Sellbom, M., & Arbisi, P. A. (2013). Post-traumatic stress disorder in veterans: The utility of the MMPI-2-RF validity scales in detecting over-reported symptoms. Psychological Assessment, 25(3), 671–678. Goy, E. R., & Ganzini, L. (2011). Prevalence and natural history of neuropsychiatric syndromes in veteran hospice patients. Journal of Pain and Symptom Management, 41(2), 394–401. Graham, J.  R. (2011). MMPI-2 Assessing personality and psychopathology (5th ed.) New York, NY: Oxford. Gray, J. L. (2006). An exploration of posttraumatic stress disorder in Persian Gulf War veterans through the eyes of the Rorschach. Dissertation Abstracts International: Section B: The Sciences and Engineering, 66(11-B), 6272. Retrieved from http://ovidsp.ovid.com/ ovidweb.cgi?T=JS&PAGE=reference&D=psyc5&NEWS=N&AN=2006-99010-378 Greene, R.  L. (2010). The MMPI-2/MMPI-2 RF:  An interpretive manual (3rd ed.) Boston: Allyn Bacon. Grove, W. M., & Vrieze, S. I. (2009). An exploration of the base rate scores of the Millon Clinical Multiaxial Inventory–III. Psychological Assessment, 21(1), 57–67. Gros, D. F., Frueh, B. C., & Magruder, K. M. (2011). Prevalence and features of panic disorder and comparison to posttraumatic stress disorder in VA primary care. General Hospital Psychiatry, 33, 482–488.

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Gros, D. F., Magruder, K. M., & Frueh, B. C. (2013). Obsessive compulsive disorder in veterans in primary care: Prevalence and impairment. General Hospital Psychiatry, 35, 71–73. Hartman, W. L., Clark, M. E., Morgan, M. K., Dunn, V. K., Fine, A., Perry, G., et al. (1990). Rorschach structure of a hospitalized sample of Vietnam veterans with PTSD. Journal of Personality Assessment, 54, 149–159. Hawkins, E. J., Malte, C. A., Imel, Z. E., Saxon, A. J., & Kivlahan, D. R. (2012). Prevalence and trends of benzodiazepine use among Veterans Affairs patients with posttraumatic stress disorder, 2003–2010. Drug and Alcohol Dependence, 124(1), 154–161. Hiller, J. B., Rosenthal, R., Bornstein, R. F., Berry, D. T. R., & Brunell-Neuleib, S. (1999). A comparative meta-analysis of Rorschach and MMPI validity. Psychological Assessment, 11, 278–296. Hoerster, K. D., Lehavot, K., Simpson, T., McFall, M., Reiber, G., & Nelson, K. M. (2012). Health and health behavior differences:  US military, veteran, and civilian men. American Journal of Preventive Medicine, 43(5), 483–489. Hoge, C.  W.,  & Castro, C.  A. (2012). Preventing suicides in US service members and veterans: concerns after a decade of war. Journal of the American Medical Association, 308(7), 671–672. Hoge C. W., McGurk D., Thomas J. L., Cox A. L., Engel C. C., & Castro C. A. (2008). Mild traumatic brain injury in U.S. soldiers returning from Iraq. New England Journal of Medicine, 358, 453–463. Holowka, D. W., Marx, B. P., Kaloupek, D. G., & Keane, T. M. (2012). PTSD symptoms among male Vietnam veterans:  Prevalence and associations with diagnostic status. Psychological Trauma: Theory, Research, Practice, and Policy, 4(3), 285–292. Holzer, L., Chinet, L., Jaugey, L., Plancherel, B., Sofia, C., Halfon, O.,  & Randolph, C. (2007). Detection of cognitive impairment with the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in adolescents with psychotic symptoms. Schizophrenia Research, 95, 48–53. Hunsley, J., & Bailey, J. M. (1999). The clinical utility of the Rorschach: Unfulfilled promises and an uncertain future. Psychological Assessment, 11, 266–277. Jackson, J. C., Sinnott, P. L., Marx, B. P., Murdoch, M., Sayer, N. A., Alvarez, J. M., . . . & Speroff, T. (2011). Variation in practices and attitudes of clinicians assessing PTSD-related disability among veterans. Journal of Traumatic Stress, 24(5), 609–613. Kaplan, M. S., McFarland, B. H., Huguet, N., & Valenstein, M. (2012). Suicide risk and precipitating circumstances among young, middle-aged, and older male veterans. American Journal of Public Health, 102, S131–S137. Keane, T. M., Malloy, P. F., & Fairbank, J. A. (1984). Empirical development of an MMPI subscale for the assessment of posttraumatic stress disorder. Journal of Consulting and Clinical Psychology, 52, 888–891. Kilbourne, A. M., Goodrich, D., Miklowitz, D. J., Austin, K., Post, E. P., & Bauer, M. S. (2010). Characteristics of patients with bipolar disorder managed in VA primary care or specialty mental health care settings. Psychiatric Services, 61, 500–507. Kinder, L. S., Bradley, K. A., Katon, W. J., Ludman, E., McDonell, M. T., & Bryson, C. L. (2008). Depression, posttraumatic stress disorder, and mortality. Psychosomatic Medicine, 70, 20–26. King, P. R., Donnelly, K. T., Donnelly, J. P., Dunnam, M., Warner, G., Kittleson, C. J., . . . & Meier, S. T. (2012). Psychometric study of the Neurobehavioral Symptom Inventory. Journal of Rehabilitation Research & Development, 49(6). Kroenke, K., Spitzer, R.  L.,  & Williams, J.  B. (2001). The PHQ-9. Journal of General Internal Medicine, 16(9), 606–613.

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Larson, E.  B., Kirschener, K., Bode, R., Heineman, A.,  & Goodman, R. (2005). Construct and predictive validity of the Repeatable Battery for the Assessment of Neuropsychological Status in the evaluation of stroke patients. Journal of Clinical and Experimental Neuropsychology, 27, 16–32. Lees-Haley, P., Smith, H., Williams, C., & Dunn, J. (1996). Forensic neuropsychological test usage: An empirical survey. Archives of Clinical Neuropsychology, 11, 45–51. Lehavot, K., Hoerster, K. D., Nelson, K. M., Jakupcak, M., & Simpson, T. L. (2012). Health indicators for military, veteran, and civilian women. American Journal of Preventive Medicine, 42(5), 473–480. Lezak, M.  D., Howieson, D.  B., Bigler, E.  D.,  & Tranel, D. (2012). Neuropsychological Assessment (5th ed.). New York: Oxford University Press. Lilienfeld, S. O., Wood, J. M., & Garb, H. N. (2000). The scientific status of projective techniques. Psychological Science in the Public Interest, 1, 27–66. Liljequist, L., Kinder, B.  N.,  & Schinka, J.  A. (1998). An investigation of malingering posttraumatic stress disorder on the Personality Assessment Inventory. Journal of Personality Assessment, 71, 322–336. Lippa, S. M., Hawes, S., Jokic, E., & Caroselli, J. S. (2013). Sensitivity of the RBANS to acute traumatic brain injury and length of post-traumatic amnesia. Brain Injury, 27, 689–695. Loring, D. W., & Bauer, R. M. (2010). Testing the limits: Cautions and concerns regarding the new Wechsler IQ and Memory scales. Neurology, 74(8), 685–690. McDonald, S.  D.,  & Calhoun, P.  S. (2010). The diagnostic accuracy of the PTSD Checklist:  A  critical review. Clinical Psychology Review, 30, 976–987. doi:10.1026/j. cpr.2010.06.012 McKay, C., Casey, J., Wertheimer, J., & Fichtenberg, N. (2007). Reliability and validity of the RBANS in a traumatic brain injured sample. Archives of Clinical Neuropsychology, 22, 91–98. Meyer, G. J. (1997a). Assessing reliability: Critical corrections for a critical examination of the Rorschach Comprehensive System. Psychological Assessment, 9, 480–489. Meyer, G. J. (1997b). Thinking clearly about reliability: More critical corrections regarding the Rorschach Comprehensive System. Psychological Assessment, 9, 495–498. Meyer, G.  J. (2000a). On the science of Rorschach research. Journal of Personality Assessment, 75, 46–81. Meyer, G. J. (2000b). Incremental validity of the Rorschach Prognostic Rating scale over the MMPI Ego Strength Scale and IQ. Journal of Personality Assessment, 74, 356–370. Meyer, G. J. (2001). Evidence to correct misperceptions about Rorschach norms. Clinical Psychology: Science and Practice, 8, 389–396. Meyer, G. J., Erdberg, P., & Shaffer, T. W. (2007). Toward international normative reference data for the Comprehensive System. Journal of Personality Assessment, 89(Suppl. 1), S201–S216. Meyer, G. J., Finn, S. E., Eyde, L., Kay, G. G., Moreland, K. L., Dies, R. R., et al. (2001). Psychological testing and psychological assessment: A review of evidence and issues. American Psychologist, 56, 128–165. Meyer, G. J., Hilsenroth, M. J., Baxter, D., Exner, J. E., Fowler, J. C., Piers, C. C., et al. (2002). An examination of interrater reliability for scoring the Rorschach Comprehensive System in eight data sets. Journal of Personality Assessment, 78, 219–274. Meyer, G. J., Hsiao, W.-C., Viglione, D. J., Mihura, J. L., & Abraham, L. H. (2013). A survey of applied clinical validity for the Rorschach. Journal of Personality Assessment, 95, 351–365.

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Meyer, G. J., & Kurtz, J. E. (2006). Advancing personality assessment terminology: Time to retire “Objective” and “Projective” as personality test descripts. Journal of Personality Assessment, 87, 223–225. Meyer, G.  J.,  & Viglione, D.  J. (2008). An introduction to Rorschach assessment. In R. P. Archer & S. R. Smith (Eds.), Personality assessment (pp. 281–336). New York, NY: Routledge. Meyer, G. J., Viglione, D. J., Mihura, J. L., Erard, R. E., & Erdberg, P. (2011). Rorschach Performance Assessment System (R-PAS): Administration, coding, interpretation, and technical manual. Toledo, OH: Rorschach Performance Assessment System. Mihura, J. L., Meyer, G. J., Dumitrascu, N., & Bombel, G. (2013). The validity of individual Rorschach variables: Systematic reviews and meta-analysis of the Comprehensive System. Psychological Bulletin, 139, 548–605. Millon, T., Davis, R.  D.,  & Millon, C. (1997). MCMI-III Manual. National Computer Systems. Millon, T., Millon, C., Davis, R.,  & Grossman, S. (2006). MCMI-III Manual (3rd ed.). Minneapolis: NCS Pearson. Millon, T., Millon, C., Davis, R.,  & Grossman, S. (2009). MCMI-III Manual (4th ed.). Minneapolis: NCS Pearson. Morey, L. C. (2007). Personality Assessemnt Inventory professional manual (2nd ed.). Lutz, FL: Psychological Assessment Resources. Morton, M.  A. (1948). The army adaptation of the MMPI. American Psychologist, 3, 271–272. Mozley, S. L., Miller, M. W., Weathers, F. W., Beckham, J. C., & Feldman, M. E. (2005). Personality Assessment Inventory (PAI) profiles of male veterans with combat-related posttraumatic stressdisorder. Journal of Psychopathology and Behavioral Assessment, 27, 179–189. Murray, H.  A. (1943). Thematic Apperception Test manual. Cambridge, MA:  Harvard University Press. Nasreddine, Z. S., Phillips, N. A., Bédirian, V., Charbonneau, S., Whitehead, V., Collin, I., . . . & Chertkow, H. (2005). The Montreal Cognitive Assessment, MoCA:  a brief screening tool for mild cognitive impairment. Journal of the American Geriatrics Society, 53(4), 695–699. Nelson, N.  W., Hoelzle, J.  B., Sims, A.  H., Goldman, D.  J., Ferrier-Auerbach, A., Charlsworth, M. J., et al. (2011). Self-report of psychological function among OEF/OIF personnel who also report combat-related concussion. The Clinical Neuropsychologist, 25, 716–740. Nunnink, S. E., Fink, D. S., & Baker, D. G. (2012). The impact of sexual functioning problems on mental well-being in U.S. veterans from the Operation Enduring Freedom and Operation Iraqi Freedom (OEF/OIF) conflicts. International Journal of Sexual Health, 24, 14–25. Parker, K.  C., Hanson, R.  K.,  & Hunsley, J. (1988). MMPI, Rorschach, and WAIS: A meta-analytic comparison of reliability, stability, and validity. Psychological Bulletin, 103, 367–373. Penk, W. E., Rierdan, J., Losardo, M., & Robinowitz, R. (2005). The MMPI-2 and assessemnt of posttraumatic stress disorder (PTSD). In J. N. Butcher (Ed.), MMPI-2: A practitioner’s guide (pp. 121–142). Washington, DC: American Psychological Association. Prins, A., Ouimette, P., Kimerling, R., Cameron, R. P., Hugelshofer, D. S., Shaw-Hegwer, J., . . . & Sheikh J. I. (2003). The primary care PTSD screen (PC-PTSD): Development and operating characteristics. Primary Care Psychiatry, 9(1), 9–14.

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Pukay-Martin, N.  D., Pontoski, K.  E., Maxwell, M.  A., Calhoun, P.  S., Dutton, C.  E., Clancy, C. P., et al. (2012). The influence of depressive symptoms on suicidal ideation among U.S. Vietnam-era and Afghanistan/Iraq-era veterans with posttraumatic stress disorder. Journal of Traumatic Stress, 25, 578–582. Randolph, C. (1998). Repeatable battery for the assessment of neuropsychological status. Bloomington, MN: Pearson. Reinert, D.  F.,  & Allen, J.  P. (2002). The alcohol use disorders identification test (AUDIT): A review of recent research. Alcoholism: Clinical and Experimental Research, 26(2), 272–279. Ritsher, J.  B. (2004). Association of Rorschach and MMPI psychosis indicators and schizophrenia spectrum diagnoses in a Russian clinical sample. Journal of Personality Assessment, 83, 46–63. Rogers, R., Salekin, R.  T.,  & Sewell, K.  W. (1999). Validation of the Millon Clinical Multiaxial Inventory for Axis II disorders: Does it meet the Daubert standard?. Law and Human Behavior, 23(4), 425–443. Rogers, R., Salekin, R. T., & Sewell, K. W. (2000). The MCMI-III and the Daubert standard: Separating rhetoric from reality. Law and Human Behavior, 24(4), 501–506. Rorschach, H. (1942). Psychodiagnostics (5th ed.). Berne, Switzerland:  Verlag Hans Huber. (Original work published 1921). Roth, R.  S.,  & Spencer, R.  J. (2013). Iatrogenic risk in the management of mild traumatic brain injury among combat veterans:  A  case illustration and commentary. International Journal of Physical Medicine & Rehabilitation, 1(1), 2–7. Russell, E. W. (2010). The ‘obsolescence’of assessment procedures. Applied Neuropsychology, 17(1), 60–67. Salley, R.  D.,  & Teiling, P.  A. (1984). Dissociated rage attacks in a Vietnam veteran: A Rorschach study. Journal of Projective Techniques & Personality Assessment, 48, 98–104. Sellbom, M., Wygant, D. B., & Bagby, R. M. (2012). Utility of the MMPI-2-RF in detecting non-credible somatic complaints. Psychiatry Research, 197, 195–201. Shaffer, T. W., Erdberg, P., & Haroian, J. (1999). Current nonpatient data for the Rorschach, WAIS-R, and MMPI-2. Journal of Personality Assessment, 73, 305–316. Sloan, P., Arsenault, L., Hilsenroth, M., Handler, L., & Harvill, L. (1996). Rorschach measures of posttraumatic stress in Persian Gulf War veterans:  A  three-year follow-up study. Journal of Personality Assessment, 66, 54–64. Sloan, P., Arsenault, L., Hilsenroth, M., Harvill, L.,  & Handler, L. (1995). Rorschach measures of posttraumatic stress in Persian Gulf War veterans. Journal of Personality Assessment, 64, 397–414. Souffront, E.  M. (1987). The use of the Rorschach in the assessment of post traumatic stress disorder among Vietnam combat veterans. Dissertation Abstracts International, 48(2-B), 573–574. Retrieved from http://ovidsp.ovid.com/ovidweb.cgi?T=JS&PAGE= reference&D=psyc3&NEWS=N&AN=1988-53912-001 Stecker, T., Fortney, J., Owen, R., McGovern, M. P., & Williams, S. (2010). Co-occurring medical, psychiatric, and alcohol-related disorders among veterans returning from Iraq and Afghanistan. Psychosomatics, 51, 503–507. Strauss, E., Sherman, E. M. S., & Spreen, O. (2006). A Compendium of Neuropsychological Tests (3rd ed). New York: Oxford University Press. Stulz, N.,  & Crits-Christoph, P. (2010). Distinguishing anxiety and depression in self-report:  Purification of the Beck Anxiety Inventory and Beck Depression Inventory-II. Journal of Clinical Psychology, 66(9), 927–940.

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Swanson, G. S., Blount, J., & Bruno, R. (1990). Comprehensive System Rorschach data on Vietnam combat veterans. Journal of Personality Assessment, 54, 160–169. Tellegen, A., & Ben-Porath, Y. S. (2008). MMPI-2-RF, Minnesota Multiphasic Personality Inventory-2 Restructured Form: Technical Manual. University of Minnesota Press. Tellegen, A., Ben Porath, Y. S., McNulty, J. L., Arbisi, P. A., Graham, J. R., & Kaemmer, B. (2003). MMPI-2 Restructured Clinical (RC) Scales:  Development, validation, and interpretation. Minneapolis: University of Minnesota Press. Tellegen, A., Ben Porath, Y. S., Sellbom, M., Arbisi, P. A., McNulty, J. L., & Graham, J. R. (2006). Further evidence on the validity of the MMPI-2 Restructured Clinical (RC) scales:  Addressing questions raised by Rogers, Sewell, Harrison, and Jordon and Nichols. Journal of Personality Assessment, 87, 148–171. Thomas, J. L., Wilk, J. E., Riviere, L. A., McGurk, D., Castro, C. A., & Hoge, C. W. (2010). Prevalence of mental health problems and functional impairment among active component and National Guard soldiers 3 and 12 months following combat in Iraq. Archives of General Psychiatry, 67(6), 614–623. Tiet, Q.  Q., Schutte, K.  K.,  & Leyva, Y.  E. (2013). Diagnostic accuracy of brief PTSD screening instruments in military veterans. Journal of Substance Abuse Treatment, 45(1), 134–142. Vanderploeg, R. D., & Belanger, H. G. (2013). Screening for a remote history of mild traumatic brain injury: When a good idea is bad. Journal of Head Trauma Rehabilitation, 28, 211–218. Viglione, D.  J.,  & Hilsenroth, M.  J. (2001). The Rorschach:  Facts, fictions, and future. Psychological Assessment, 13, 452–471. Weathers, F., Litz, B., Herman, D., Huska, J.,  & Keane, T. (October 1993). The PTSD Checklist (PCL): Reliability, validity, and diagnostic utility. Paper presented at the Annual Convention of the International Society for Traumatic Stress Studies, San Antonio, TX. Weathers, F., Litz, B., Huska, J., & Keane, T. (1994). PTSD Checklist—Military version. Boston, MA: National Center for PTSD, Behavioral Sciences Division. Weathers, F., Litz, B., Huska, J.,  & Keane, T. (1994). PTSD Checklist—Civilian version. Boston, MA: National Center for PTSD. Behavioral Sciences Division. Weathers, F., Litz, B., Huska, J.,  & Keane, T. (1994). PTSD Checklist—Specific version. Boston, MA: National Center for PTSD. Behavioral Sciences Division. Wechsler, D. (2008). Wechsler Adult Intelligence Scale, Fourth Edition (WAIS–IV). San Antonio, TX: Pearson. Weiner, I. B., & Greene, R. L. (2008). Handbook of personality assessment. Hoboken, NJ: Wiley. White, R., Barber, C., Azrael, D., Mukamal, K. J., & Miller, M. (2011). History of military service and the risk of suicidal ideation: Findings from the 2008 national survey on drug use and health. Suicide and Life-Threatening Behavior, 41, 554–561. Widome, R., Laska, M. N., Gulden, A., Fu, S. S., & Lust, K. (2011). Health risk behaviors of Afghanistan and Iraq War veterans attending college. American Journal of Health Promotion, 26, 101–108. Wilde, M. C. (2006). The validity of the Repeatable Battery of Neuropsychological Status in acute stroke. The Clinical Neuropsychologist, 20, 702–715. Wilkins, K. C., Lang, A. J., & Norman, S. B. (2011). Synthesis of the psychometric properties of the PTSD checklist (PCL) military, civilian, and specific versions. Depression and Anxiety, 28(7), 596–606. Wolf, E. J., Miller, M. W., Orazem, R. J., Weierich, M. R., Castillo, D. T., Milford, J. et al. (2008). The MMPI-2 Restructured Clinical Scales in the assessment of posttraumatic stress disorder and comorbid disorders. Psychological Assessement, 20, 327–340.

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Wood, J. M., & Lilienfeld, S. O. (1999). The Rorschach Inkblot Test: A case of overstatement? Assessment, 6, 341–349. Wood, J. M., Nezworski, M. T., Garb, H. N., & Lilienfeld, S. O. (2001). The misconception of psychopathology: Problems with norms of the Comprehensive System for the Rorschach. Clinical Psychology: Science and Practice, 8, 350–373. Wood, J. M., Nezworski, M. T., & Stejskal, W. J. (1996). The Comprehensive System for the Rorschach: A critical examination. Psychological Science, 7, 3–10. Wood, J. M., Nezworski, M. T., & Stejskal, W. J. (1997). The reliability of the Comprehensive System: A comment on Meyer (1997). Psychological Assessment, 9, 490–494. Yano, E. M., Chaney, E. F., Campbell, D. G., Klap, R., Simon, B. F., Bonner, L. M., Lanto, A. B., & Rubenstein, L. V. (2010). Yield of practice-based depression screening in VA primary care settings. Journal of General Internal Medicine, 27(3), 331–338.

3

Psychological Assessment of Veterans in Long-Term Care M ICHAEL L. DREXLER

The influence of psychological assessment and intervention in long-term care (LTC) settings has increased dramatically over the past several decades, and psychological practice in such venues has become ever more elaborated and developed as an area of specialty practice (American Psychological Association [APA], 2004; Norris, Molinari, & Ogland-Hand, 2002), with standards available for guidance (Lichtenberg et  al., 1998). It is well known that one of the fastest growing segments in the US population is made up of those considered older, with the age of 65 years and up often considered “geriatric.” Although estimates suggest that the total number of veterans from earlier born cohorts is declining, the proportion of older veterans has been increasing dramatically (though this estimate may need to be modified due to the influence of more recent wars) (Richardson & Waldrop, 2003). Furthermore, as pointed out by those authors, the proportion of older persons in the veteran population far exceeds the proportion of older persons in the US population at large. By 2020, it has been estimated that there will be 7.6 million US veterans aged 65 or older. Although most will be male, the number of female veterans is growing. In 2000, over 5% (1.4 million) of all veterans and 3% (325,000) of veterans age 65 or older were female. Among female veterans, the proportion age 65 or older is projected to be 20% in 2020 (Yarvis, Yoon, Amenuke, Simien-Turner, & Landers, 2012). As might be expected based on the overall “graying of America,” along with the above statistics about veterans, Department of Veterans Affairs (DVA) hospitals are seeing an increase in the proportion of members of earlier born cohorts being served by their facilities. The largest proportion are male, many with injuries or illnesses sustained during their service. Many are able to receive LTC in the Community Living Centers (CLCs) associated with DVA facilities. The DVA operates 132 CLCs (DVA, 2012). Formerly known as VA Nursing Home Care Units, CLCs provide care to eligible veterans with sufficient functional impairments. Whereas the “typical” freestanding nursing home in the community usually serves more women than men,

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within DVA this demographic breakdown is quite different. For example, a CLC with 100 beds might be serving about 95 male and 5 female veterans at any one time. Among the veterans served in CLCs are those with chronic, stable conditions including dementia, those requiring rehabilitation or short-term specialized services such as respite or intravenous therapy, those with chronic physical conditions incompatible with more independent living, and those who need comfort and care at the end of life. While in no way are all those in CLCs over the age of 65 years, as veterans from any age group can be served as long as they have skilled nursing needs, the largest proportion is likely to be older. Not surprisingly, many have commented on the increased complexity of the mental health landscape in various long-term care facilities (e.g., Drexler & Walker, 2003), with the presence of many comorbid psychiatric conditions, as will be discussed later in this chapter. Recognizing that complexity, the Uniform Mental Health Services in VA Medical Centers and Clinics handbook (Department of Veterans Affairs, Veterans Health Administration, 2008) specifies that CLCs are required to provide a full range of integrated mental health services, including at a minimum one full-time equivalent (1.0 FTE) psychologist for a 100-bed facility. Among the required services specifically noted by that document are psychological assessments and cognitive evaluations. To summarize and reiterate, CLCs often serve a number of populations simultaneously, including those who will receive long-term care, others who are receiving subacute rehabilitation services and who may stay only a few months, as well as those with chronic psychiatric conditions (such as schizophrenia), generally provided that they also have skilled nursing needs. In addition, some CLCs also provide hospice and palliative care. Among the common referral questions (which overlap substantially with referrals to neuropsychology) are those relating to the presence and severity of cognitive, psychiatric, and health- or facility-related adjustment problems (see Table 3.1). In general, one suggested rule for psychological assessment is to follow what has been called an “evidence-based assessment” approach (Hunsley & Mash, 2010). That Table 3.1.  Common Clinical Conditions Prompting Referral for Psychological Evaluations in LTC Depression and suicidality Anxiety Exacerbation of PTSD Somatization Undue dependency on others Psychosis, whether long-standing or more recent in development Cognitive impairment/dementia/delirium Chronic pain Substance abuse Adjustment to decline in health Adjustment to changing physical status Adjustment to difficulty with the group living situation Various behavioral problems, such as altercations with others (both staff and other residents).

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is, whenever possible, psychometrically strong measures should be used to assess the constructs targeted in the assessment. The term “psychometrically strong” is used to describe instruments with consistent empirical evidence of reliability, validity, and, ideally, clinical utility. Note that it has been pointed out that psychometric evidence is always conditional, based on sample characteristics and assessment purposes, and that supporting evidence to consider in selecting instruments must be relevant to the specific purpose of use (Hunsley & Mash, 2010). Considerations such as validity, specificity, sensitivity, positive predictive power, and negative predictive power do not diminish in importance in the geriatric LTC arena. In fact, given the complexity of the setting, the range of comorbid conditions encountered, and the sometimes profound questions being addressed in such a setting (e.g., Is this veteran able to make his or her own decisions regarding basic medical care?), these psychometric considerations may be magnified in terms of importance. In addition, if the tests and procedures chosen provide the practitioner with information that will help in completion of the required Resident Assessment Instrument of the Minimum Data Set (DVA, 2013), which is used to document such things as behavioral problems, response to intervention, and use of psychotropic mediation, and which some psychologists working in LTC within DVA are asked to help complete, this will further aid in efficiency. When questions are raised about the appropriateness of the use of psychological testing and standardized procedures in LTC in general, it may help to bear in mind the evidence supporting the use of such procedures (Meyer et al., 2001). Based on meta-analyses, these authors pointed out that the evidence supports the following conclusions: (a) psychological test validity is strong and compelling; (b) psychological test validity is comparable to medical test validity; (c) distinct assessment methods provide unique sources of information; and (d) clinicians who rely exclusively on interviews are prone to incomplete understandings. Nevertheless, in addition to psychological testing, direct observation often contributes a great deal to an understanding of patients. For example, when the question includes one of “wandering,” much information that is helpful in developing an approach to intervention can be gleaned from careful, standard observation of the behavior (Schonfeld et al., 2007). Furthermore, the importance of collateral information (i.e., from those who know the patient well) cannot be overestimated, but the need to follow appropriate legal and ethical guidelines in gaining such information is not diminished in LTC, as discussed more fully below. Importantly, the knowledge base needed to address questions arising in the context of LTC, particularly capacity issues in a frail, medically complex older adult living in a nursing home (as well as many healthcare and family systems issues), but is even more complex than the knowledge base needed to assess a medically healthy but psychiatrically ill older adult who is referred by a court in a guardianship proceeding (American Bar Association Commission on Law and Aging  & APA, 2005). Furthermore, the Guidelines for Psychological Practice in Health Care Delivery Systems (Guidelines; APA, 2013) call for psychologists to gain and maintain appropriately specialized competence in the systems in which they work. Issues of the required knowledge base, appropriate training, and competence for practice in LTC have been addressed (e.g., Division 20, 2000), and draft guidelines for specialty practice within geropsychology are under development (APA, 2004; Molinari, 2003; 2010; Qualls, Segal, Norman, Niederehe, & Gallagher-Thompson, 2002).

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The Guidelines (APA, 2013) call for psychologists to seek to understand the internally and externally imposed expectations and requirements of the systems within which they practice. Certainly, in working in LTC, it is of critical importance for the psychologist to be aware of and well-versed in these issues. Thus, having a working knowledge of the setting is needed for appropriate practice. In LTC, one of the psychologist’s roles on the interdisciplinary team is to detect and address cognitive, affective, and behavioral disturbance, using psychological diagnostic tools (Lichtenberg et al., 1998). These tools may include cognitive, affective, behavioral, and personality assessments; individual, family, and group therapies; behavioral interventions; and staff education regarding the psychological needs of, and clinical management strategies for, residents in LTC facilities. Furthermore, given the complex population in nursing homes, assessment for a variety of concerns may be needed. For example, in addition to assessing for mood and other disturbances, the psychologist may be called upon to provide an assessment for rehabilitation purposes (Lawton, Whelihan, & Lesher, 1985). An ability to provide treatment as well as education adds to the value of the assessment provided. Suicidality in nursing homes is an area of particular concern, and assessing for suicidal ideation should be a routine part of screening (Reiss  & Tishler, 2008a, b; Scocco, Fantoni, Rapattoni, de Girolamo, & Pavan, 2009), leading to effective interventions (Bruce et  al., 2004). Direct forms of reported suicide in nursing homes have included jumping, cutting, overdosing, drowning in the bathtub when unattended, and suffocating. Suicide attempts or self-harm behavior, such as refusing food and medications, is an even larger issue in nursing homes. Upon admittance, all residents should be screened for depression and suicidal ideation by standardized tools such as the Geriatric Depression Scale for cognitively intact residents and the Cornell Scale for Depression in Dementia for individuals with cognitive impairment (Reiss & Tishler, 2008a, b). Although less common, the psychologist may be asked to provide some assessment of the general “social climate” of the residential care facility. Such an assessment can aid in program development and with multiple aspects of quality improvement. PSYCHOLOGICAL ASSESSMENT ISSUES IN DVA LONG-TERM CARE The Guidelines (APA, 2013) call for psychologists to remain cognizant of their ethical and legal obligations as members of a distinct and autonomous profession, which can be extremely important when working with veterans in the complex, interdisciplinary environment of the CLC. Furthermore, those veterans in LTC are often considered an “at risk” population (Morgan, 2002), suggesting that concerns about such things as informed consent, clarification of roles and services (APA, 2013), and the need for clarity about the reasons for referral and the ends to which the information will be used should be raised to a high level. For example, while it appears to be common and good practice to obtain collateral information about the veteran (as noted earlier), the clinician must remain aware that the older person retains the right to confidentiality, and speaking to collaterals should be done only with permission (though the presence of severe cognitive problems may complicate the situation). According to Segal, Coolidge, and Hersen (1998), the reasons for testing or clinical assessment may include (a) differential diagnosis, (b) finding out what types of

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problems the person is experiencing and what may have contributed to the problem, (c) assisting in clarification of personality features, (d) helping to develop initial case conceptualization and intervention plans, and (e)  evaluating the effects of treatment. For an overview of assessment in geriatric settings in general, see Lichtenberg (2010).

Comorbid Conditions, Common Findings, and Typical Profiles The prevalence of diagnoses of depression, alcohol abuse, post-traumatic stress disorder (PTSD), dementia, chronic pain, other mental illnesses, and general psychosocial dysfunction is high among veterans from all combat eras (Gaylord, 2006; Waldron-Perrine & Bieliauskas, 2012). The transition into the nursing home can lead to considerable stress, caused by a change in status and the need to become accustomed to an entirely new schedule and unfamiliar people, shared living space, and altered eating habits, as well as mourning the loss of function and autonomy.

Depression Not surprisingly, perhaps, depression can result. Prevalence estimates of major depression in older adults vary across settings, with increases in prevalence as one moves from outpatient to inpatient settings. Among hospitalized older adults, prevalence rates of major depression range from 10% to 12% (Blazer, 1994; Koenig, Meador, Cohen,  & Blazer, 1988), and estimates for major depression among LTC residents are higher still, ranging from 12.4% to 14.4% (Parmalee, Katz, & Lawton, 1989; Teresi, Abrams, Holmes, Ramirez, & Eimicke, 2001). Depending on the methodology used, some estimates of the base rate of depression in general in nursing homes run much higher, and the influence of such mood disorders on response to medical treatment and quality of life underscores the need for careful assessment, leading to intervention. At this point, veterans are routinely screened for the presence of depression when they enter CLCs and periodically thereafter. According to the DVA National Registry for Depression, 11% of veterans aged 65 years and older have a diagnosis of major depressive disorder, a rate more than twice that found in the general population of adults aged 65 and older. The actual rate of depression among such older veterans may be even higher, because not all veterans with depression receive a diagnosis from their health care provider. Older adults do not necessarily experience sadness when they are depressed. Instead, older persons may report problems with their memory or unexplained pain, fatigue, or other unexplained somatic symptoms. Other signs are anxiety, hopelessness, helplessness, and irritability. One of the most serious consequences of depression is suicide. Veterans aged 65 and older are also at high risk compared to middle-aged (45–64) veterans. Other serious consequences include increased risk for medical problems, cognitive decline and dementia, and mortality. Depression in late life may be brought on by losses or serious challenges such as the death of a spouse, family member, or pet; medical problems; disability; or even retirement. For many, the transition to a nursing home may lead to depression. A veteran who has worked all of his or her life may have trouble coping with the lack of “something to do” every day, may experience financial strain, may feel that he is useless, or may become isolated from other people. Various medical conditions, such

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as diabetes and stroke, make older veterans particularly vulnerable to developing depression due to their effects on blood flow to the brain.

Substance Abuse As noted previously, the base rate of substance abuse, particularly alcohol abuse, must be considered in the aging veteran population. Contrary to possible myths or ageist assumptions, many of those entering CLCs have a very significant history of substance misuse or abuse, often quite chronic in nature. While the use of alcohol may be curtailed somewhat by inpatient admission, CLCs are not locked facilities, and use of alcohol may continue. Furthermore, use of other substances may continue as well. Use of marijuana is commonly encountered. While not legal on DVA (i.e., federal) property, a given CLC may be located in a state in which marijuana use is sanctioned (perhaps for medicinal purposes). As with alcohol, use may continue. Experience has shown that other drugs may be present as well. In addition, there are times when individuals in LTC may appear to request increasing amounts of a medication, particularly for pain, and this may become a source of concern (Malmstrom & Tait, 2010). Risk factors for a range of substance abuse problems in older individuals are discussed by Blow et al. (1998).

Post-Traumatic Stress Psychologists working within VA facilities will likely be very familiar with some of the screening tools for PTSD. Not uncommonly, entering LTC may lead to an exacerbation of PTSD symptoms or sometimes the surfacing of PTSD that previously had not been clearly manifest. Symptoms of PTSD can complicate a stay in LTC, can interfere with treatment adherence, and can interfere with development of an alliance with the treatment team. Importantly, recent research also shows that nearly 40% of veterans aged 60 and over in treatment for depression have a diagnosis of PTSD, clearly suggesting that the clinician should be alert to screen for this additional possible comorbid condition.

Dementia Furthermore, dementia is a possible comorbid condition that must be considered. In assessing mood, it should be noted that dementia appears to influence depression and vice versa. Depression can be a psychological reaction to dementia. In their early stages, depression and dementia in older adults can present similarly. For example, many older veterans with depression complain of memory difficulties. Although this chapter is not meant to provide an overview of neuropsychological assessment, some screening procedures are covered, given the substantial overlap of neurocognitive presentations and psychiatric dysfunction, particularly in LTC. Although the geropsychologist may not be a neuropsychologist per se, proficiency in screening for the presence of common neuropsychological syndromes may be achieved with appropriate consultation and training, with referral to neuropsychology as indicated for questions requiring specialty training (as might be true, for example, if the team were to ask for a differential diagnosis between types of early dementia in the context of multiple physical and cognitive problems). For a more complete overview of relevant neuropsychological assessment including such practice in LTC settings, see

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Woodard (2010) and Waldron-Perrine & Bieliauskas (2012), as well as Bush (2012), for coverage of neuropsychological assessment of veterans in general.

Other Disorders While the previous information provides an overview of some of the psychological conditions and issues that are quite common in LTC, it is important to add that the full range of mental health diagnoses can be seen in the elderly (Abeles, Cooley, Deitch, Harper, Hinrichsen, Lopez, & Molinari, 1998). For example, the prevalence of psychotic and personality disorders in LTC facilities has increased over the last few decades. In particular, the challenges associated with caring for individuals with personality disorders in LTC have been discussed by others (e.g., Hall, Hategan, & Bourgeois, 2012; Himelick & Walsh, 2002; Rosowsky & Gurian, 1992), and assessment of such disorders is discussed by Oltmanns and Balsis (2010).

Abilities/States/Traits to Be Assessed Although there is a range of comorbities experienced by veterans in LTC, some conditions are more common than others with aging (Abeles, Cooley, Deitch, Harper, Hinrichsen, Lopez, & Molinari, 1998). Psychologists may well encounter a wide range of concerns and diagnoses, and will approach assessment accordingly. It can be helpful to determine the level of intellectual and cognitive ability in some domains, as such factors can often play a role in how mental and behavioral problems manifest. In addition to the information from testing, the electronic medical record will often contain the results of prior evaluations by psychologists and others. For example, professionals such as occupational therapists will often assess an individual’s ability to perform activities of daily living and instrumental activities of daily living, and information obtained from those evaluations can be very valuable in addressing such questions about the veteran’s capacity to live independently. Use of observational and collateral information, quantitative measures, and background information from medical records give the clinician diverse information with which to make diagnostic determinations and offer beneficial recommendations. One of the more common questions arising in the context of LTC is the capacity for decision-making. Approaches to addressing competence and decision-making capacity in geriatric healthcare settings are discussed in detail elsewhere (e.g., Grisso, 1994; Lichtenberg, 1994; Moye, 1996; Moye  & Braun, 2010)  and will not be fully reviewed here. However, it should be noted that there are a number of specific questions that can arise regarding capacity, and the clinician may be asked to address decision-making for at least the following concerns:  medical decisions, financial decisions, sexual consent, testamentary capacity, driving, and independent living (American Bar Association Commission on Law and Aging & APA, 2005). Of course, it may be necessary to address the question of “undue influence” as well. Importantly, decision-making has been studied in VA nursing home residents. For example, Fitten, Lusky, and Hamann (1990) investigated treatment decision-making in VA nursing home residents. While some methodological questions have been raised about aspects of the study (e.g., Lichtenberg, 1998, p. 159), the conclusion was that cognitive tests alone may not provide the best estimate of decision-making capacity,

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a view expressed clearly by others (e.g., American Bar Association Commission on Law and Aging & APA, 2005).

Test Measures and Procedure Options Given the multiple medical and psychiatric comorbidities that may be encountered in the LTC setting, it is important to select an assessment battery that maximizes the amount of information that can be collected in a minimum amount of time. There is a wide range of available tests and procedures. The LTC setting does not categorically rule out the use of any assessment device in the armamentarium of the psychologist. However, given the considerations of following an evidence-based practice, particularly in working with this complex population, it is important that the tests and procedures selected have demonstrated reliability and validity, and have been reasonably, rationally, and logically chosen to address the referral question at hand. The following provides an overview of some of the more commonly employed instruments in the LTC setting. Note that the review is necessarily selective given the scope of this chapter and space constraints.

Inventories There are a number of inventories that can be used in LTC, both for administration to the individual and also for staff members or other collaterals to rate the individual. Note carefully that such screening inventories generally are not designed to provide diagnoses per se, but elevated scores underscore the need for more thorough assessment of mood or other issues through detailed interview and other appropriate means. Some of the more commonly encountered instruments in this setting are described here.

Depression The Geriatric Depression Scale (GDS; Gallagher, 1986b; McGivney, Mulvihill,  & Taylor, 1994; Yesavage et al., 1982, 1983) is one of the most commonly used screening instruments in CLCs within VA settings. The test has been validated for use in the nursing home setting (McGivney, Mulvihill,  & Taylor, 1994), and its relationship to the Minimum Data Set (MDS, required in nursing homes and CLCs) has been investigated (Koehler et al., 2005). The complete GDS is 30 items in length and utilizes a true/false format in asking questions about various symptoms of depression. Scores run from 0 to 30, with a number of possible cutoff scores having been suggested (e.g., “10 or greater” by McGivney, Mulvihill, & Taylor, 1994). There are a number of advantages to using this test. It can be completed in a few minutes, scoring is quite rapid, and it can be administered directly to the patient or can be read to them. The true/false format in asking questions about various symptoms of depression appears to make it cognitively simpler than the Beck Depression Inventory (BDI; Beck, 1987) (described later in this chapter). The GDS does not ask about the same vegetative signs as the BDI, so the examiner needs to ask separately about sleep and appetite (and then take care in interpretation, given possible normative changes in these functions with age). Interestingly, studies have suggested that the GDS remains valid into progressive dementia for a longer period of time than

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the BDI, apparently due to the relative cognitive simplicity of the GDS. While the concerns about the possibility of inflated scores on the BDI due to misunderstanding normative changes in appetite and sleep with aging have not been supported by research, the demonstrated retention of validity during progressive cognitive change would seem to argue strongly in favor of the GDS. With outpatients, both the GDS and the BDI have been found to be sensitive in detecting clinical depression (Olin, Schneider, Eaton, Zemansky, & Pollock, 1992). However, individuals were more likely to endorse multiple responses on BDI items, suggesting that the GDS is simpler for older adults to complete. Furthermore, the GDS is available in a short form, 15 items in length (Sheikh & Yesavage, 1986). At some CLCs, the short form is administered to all patients who are admitted (sometimes by social work and/or nursing in addition to psychology), with those who score above a cutoff (generally 5) being referred for more extensive evaluation, including at least administration of the full GDS and a clinical interview by the psychologist or other mental health professional. In addition, a 30-item collateral version is available (Nitcher, Burke, Roccaforte, & Wengel, 1993), which can be completed by collateral sources such as family members, nursing staff, and others familiar with the veteran. Reliance on collateral reports can be quite important when the veteran has memory problems or denies depressive symptoms despite objective signs or other evidence that the individual is depressed. The format of the collateral version parallels the full version. Early studies of the GDS support its validity and reliability (Parmelee, Lawton, & Katz, 1989), with high internal consistency and good test-retest reliability. The GDS-based classifications of respondents as suffering possible major, minor, or no depression were fairly consistent with those based on a symptom checklist and with clinical diagnoses. However, both the GDS and the checklist yielded high false negative rates vis à vis clinically diagnosed minor depression. Of note, there were no differences in reliability or validity for cognitively impaired and intact groups. Responses did not vary with age or length of institutionalization, but there was a positive correlation with functional disability and ill health (supporting the usefulness of this tool with the nursing home population). The BDI and the BDI-II (Beck, Steer, & Brown, 1996) are well-known self-report instruments and have been used with the elderly (e.g., Brown, Schulberg, & Madonia, 1995). While most often administered directly, with the patient filling out the form himself, the BDI/BDI-II can be read to the individual, with the examiner marking answers, if needed (though this modification can raise concerns about diminished validity). While the BDI/BDI-II has demonstrated good validity and is reliable enough that many clinicians reportedly use it for serial assessment (assuming that changes in scores reflect changes in the severity of depressive symptoms rather than inherent limitations in reliability), some concerns about its use with the elderly have been raised. The BDI/BDI-II utilizes a multiple-choice format, often with several alternative answers from which to select. The BDI-II contains 21 questions, each answer being scored on a scale value of 0 to 3. Some suggested cutoffs differ from the original:  0–13:  minimal depression; 14–19:  mild depression; 20–28:  moderate depression; and 29–63: severe depression. Higher total scores indicate more severe depressive symptoms.Some have questioned whether or not the format (i.e., multiple choice) might be too complex, particularly for older individuals with cognitive

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problems. Furthermore, some items assess change in such vegetative functions as eating and sleeping, raising questions about inflating scores in older individuals (in whom changes in appetite and sleep may be normative), though subsequent studies have not been striking in terms of elevated scores due to such changes in the elderly. Norris, Molinari, & Ogland-Hand, 1987, compared the sensitivity and specificity of the GDS and the BDI in a sample of elderly outpatients with medical problems. These authors reported results for a number of cutoff scores for both instruments and discussed the implications in terms of misclassification. All things considered, the GDS has been recommended for use with the elderly, particularly in view of the relative volume of literature supporting this measure with the elderly (Tuokko & Hadjistavropoulos, 1998). Nevertheless, it should be noted that questions have been raised about the psychometric properties of the GDS when it is used with the elderly in nursing homes (Montorio & Izal, 1996). Although the results for the reliability of the GDS with institutionalized elderly people are generally consistent with those found in the original research (Lesher, 1986), and the validity of the GDS is supported by its convergence with the BDI, the sensitivity and specificity of the scale when it is used with institutionalized elderly can vary, underscoring the need for care in interpretation (Lesher, 1986; Parmelee, Katz, & Lawton, 1989), as would be true for any screening instrument not designed for “stand-alone” diagnosis.

Substance Use The CAGE Questionnaire (Ewing, 1984), the name of which is an acronym for its four questions, is used to screen for alcohol abuse. The questions are as follows: (1) Have you ever felt you needed to Cut down on your drinking? (2) Have people Annoyed you by criticizing your drinking? (3)  Have you ever felt Guilty about drinking? (4) Have you ever felt you needed a drink first thing in the morning (Eye-opener) to steady your nerves or to get rid of a hangover? Two “yes” responses indicate that the possibility of alcoholism should be investigated further. Similarly, the Michigan Alcohol Screening Test (MAST-G; Blow, Brower, Schulenberg, Demo-Dananberg, Young, & Beresford, 1992) has been recommended to screen for alcohol abuse among older adults (Blow et al., 1998; Barry & Blow, 2010; Blow, Cook, Booth, Falcon, & Friedman, 1992). These measures are readily available to most VA providers and are quick and efficient. However, they are generally face-valid measures and may be subject to deliberate distortion, further necessitating the need for a carefully taken history and, when possible, collateral information. Some clinicians have found the Alcohol Use Disorders Identification Test (AUDIT; Babor, de la Fuenta, Saunders, & Grant, 1992) to be of value as well. Regarding other substance abuse questions, a sequential approach that looks at various dimensions of an older adult’s suspected problem in stages is generally recommended (Blow et al., 1998). For example, use of the appropriate Structured Clinical Interview for DSM IV (SCID) may be of considerable help. Nevertheless, there may be times when it is appropriate to refer to more specialized providers of substance abuse services within the VA system to gain a full picture of a veteran’s suspected problems in this area. As for abuse of prescribed medications, nowhere is the need more apparent for interdisciplinary collaboration in assessing and approaching the issue.

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Post-Traumatic Stress Although other chapters address the assessment of PTSD in more detail (see Chapter  11), it is noted here that the PTSD Checklist-Military Version (PCL-M; Kimerling, Prins, Yeager, & Magruder, 2010) is efficiently administered and is quite available within VA settings. However, the instrument is very face valid. Another instrument, the Trauma Symptom Inventory-2 (TSI-2), is somewhat longer and more complex to score, but has the advantage of screening for reactions to a range of stressors and also includes validity scales. The TSI-2 is designed to evaluate post-traumatic stress and other psychological sequelae of traumatic events, including the effects of sexual and physical assault, intimate partner violence, combat, torture, motor vehicle accidents, mass casualty events, medical trauma, traumatic losses, and childhood abuse or neglect. The inventory consists of 136 items, takes about 30 minutes to administer and 30 minutes to score, and has norms through the age of 88 years (Briere, 2010).

Generalized Anxiety Anxiety as distinct from PTSD also may be an important part of the clinical picture, at times in its own right as a specific diagnosis, and at times as a co-feature of depression or some other disorder (Carmin & Ownby, 2010). As noted by Tuokko and Hadjistavropoulos (1998), the professional must differentiate anxiety disorders from physical disorders and conditions associated with anxiety-like symptoms, such as hyperthyroidism, small stroke and ischemic attacks, and the use of substances such as caffeine and alcohol. While several of the measures described in this chapter (e.g., BSI, MMPI-2, SCL-90-R, TSI-2) address anxiety, there are a few additional specific measures that have been useful in working with the elderly. These measures include the State-Trait Anxiety Inventory (STAI: Knight, Waal-Manning, & Spears, 1983; Spielberger et al., 1970), which has been studied to some degree in the elderly (Nesselroade, Mitteness, & Thompson, 1984). However, it has been suggested that the form is too complicated for some elders to complete (Patterson, O’Sullivan, & Spielberger, 1980; Rankin, Gfeller, & Gilner, 1993), and some have suggested that the simplified form may be more appropriate for elders (Spielberger, Gorsuch, Lushene, Montouri, & Platsek, 1973). The Beck Anxiety Inventory (BAI; Beck  & Steer, 1993)  has been used with the elderly. Similar to the BDI described earlier, the BAI utilizes a multiple-choice format, often with several alternative answers from which to select. The BAI contains 21 questions, each answer being scored on a scale value of 0 to 3. Higher total scores indicate more severe anxiety symptoms. Exploration of the psychometric properties of the BAI provides support for the usefulness of the measure for assessment of the elderly (Morin et al., 1999; Wetherell & Areán, 1997). However, care in the use of the BAI would seem advised in that the BAI may overestimate anxiety in older adults due to inclusion of somatic symptoms caused by medical illness (Morin et al., 1999; Wetherell & Gatz, 2005). The relative cognitive complexity of the format might also be noted as a possible problem when assessing those who have cognitive impairment. A possible newer alternative that will be noted here is the Geriatric Anxiety Inventory (GAI; Pachana et al., 2007). This inventory is a 20-item self-report inventory that employs a dichotomous response format relating to the last week. Although

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memory for the prior week is required, the relatively simple format would support its use with those who have cognitive impairment. This inventory would appear to be a strong possible choice for use with the elderly in general (Edelstein, Drozdick, & Ciliberti, 2010), and further research with the instrument will provide additional information about its utility. For a more complete discussion of assessment of anxiety in aging in general, see Edelstein & Segal (2011).

Combined Psychopathology Inventories The Minnesota Multiphasic Personality Inventory, second edition (MMPI-2), and MMPI-2-RF (Restructured Form) are widely used and were empirically developed (Butcher, Dahlstrom, Graham, Tellegen,  & Kraemer, 1989; Greene, 2011). The MMPI-2 has been used with elderly individuals (reviewed by Tuokko  & Hadjistavropoulos, 1998). In a review of the literature, Graham (1993) found that older individuals obtain somewhat higher scores on Scales 1 (Hypochondriasis), 2 (Depression), 3 (Hysteria), and 0 (Social Introversion), and lower scores on Scales 4 (Psychopathic Deviate) and 9 (Mania). Other studies exploring the performance of older individuals on the MMPI-2 have been reported for both men and women (Butcher et al., 1991; Priest & Meunier, 1993). Concerns about the use of the MMPI with older individuals have been raised in the literature, and it should be noted that Smith, Patterson, Grant, and Clopton (1989) provided norms on a short version of the original test that are of relevance in assessment of the elderly. It has been suggested that the clinician may want to plot the MMPI profile based on norms for older persons in addition to the profile based on the normative sample (Dahlstrom, Welsh,  & Dahlstrom, 1972; Tuokko  & Hadjistavropoulos, 1998). However, others have pointed out that the validation and interpretation information is based on the normative sample (Greene, 1980), and the approach reported by Smith et al. (1989) was based on noninstitutionalized older persons. Thus, such approaches should be used with considerable care. Information about the MMPI-2 and MMPI-2-RF is also reviewed by Greene (2011). Given the length and complexity of the MMPI-2 or MMPI-2-RF, it is important to note some further alternatives for assessing the elderly across a range of possible psychopathologies. The Clinical Assessment Scales for the Elderly (CASE; Reynolds & Bigler, 2001) is an instrument that which was developed specifically to assess for the most prominent DSM-IV Axis I clinical disorders among the elderly. The instrument is normed for individuals from ages 55 to 90 years. The CASE consists of a self-rating form (Form S) and an “other-rating form” (Form R) that can be completed by a knowledgeable caregiver (e.g., spouse, child, home healthcare worker, sibling). Form R is especially useful to verify the information provided by the patient or when the patient is unable to complete the assessment due to physical or cognitive difficulties. Items are designed to be as free as possible of gender or ethnicity bias. The CASE gives information across 10 clinical scales: Anxiety (ANX), Cognitive Competence (COG), Depression (DEP), Fear of Aging (FOA), ObsessiveCompulsiveness (OCD), Paranoia (PAR), Psychoticism (PSY), Somatization (SOM), Mania (MAN), and Substance Abuse (SUB). The instrument gives a valuable Fear of Aging scale that assesses an individual’s level of apprehension about the aging process. There are three validity scales that can be used to address the validity of the assessment. The test can be completed in 40 minutes or less, and it takes about

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10 minutes to score. To further enhance efficiency, there is a short form available (i.e., the CASE-SF; Reynolds & Bigler, 2001), which takes about 20 minutes to administer and 10 minutes to score. The Symptom Checklist-90 (SCL-90; Derogatis, 1977), Symptom Checklist-90-Revised (SCL-90-R), and the Brief Symptom Inventory (BSI; Hale, Cochran,  & Hedgepeth, 1984)  have been used with veterans. The BSI is a scale derived from the SCL-90-R, and consists of 53 items used to measure psychopathology across various relevant dimensions in the elderly; it has been used to assess those in nursing homes (Hale, Cochran, & Hedgepeth, 1984). There are also other scales derived from the SCL-90-R that may be of use with veterans. For example, a scale for assessing war-zone-related post-traumatic stress disorder (WZ-PTSD scale: Weathers et al., 1996) was derived from the SCL-90-R and can be used when other methods of assessing for PTSD are not appropriate or available (SCL-90; Derogatis, 1977).

Additional Inventories There are a number of additional inventories that have been developed for geriatric practice, such as the Center for Epidemiologic Studies–Depression Scale (CES– D; Raddloff, 1977; Zung  & Green, 1973), the Schedule for Affective Disorders and Schizophrenia (SADS; Gallagher, 1986a; Spitzer  & Endicott, 1978); the Zung Self-Rating Depression Scale (Zung & Zung, 1986), and the Zung Self-Rating Anxiety Scale (Zung, 1971). Interested readers are directed to the references for those measures.

Structured Interviews When self-report is not considered the most useful or valid method of assessment, examiner-completed inventories are available. The collateral version of the GDS was previously described. Another such instrument is the Cornell Scale for Depression in Dementia (CSDD; Alexopoulos, Abrams, Young, & Shamoian, 1988), which was specifically developed to assess signs and symptoms of major depression in patients with dementia. The CSDD uses a comprehensive interviewing approach that derives information from the patient and an informant. The final ratings of the CSDD items represent the rater’s clinical impression rather than the responses of the informant or the patient per se. The CSDD takes approximately 20 minutes to administer and can be of use when there are questions about the reliability of interview responses. Regarding the CSDD, Kurlowicz, Evans, Strumpf, and Maislin (2002) demonstrated that in frail, institutionalized older adults with high rates of dementia, medical illness, and functional disability, such depression measurement methods that are less dependent on items highly sensitive to comorbid conditions and not necessarily associated with depression may be of considerable value. Also available for the practitioner to complete are the Hamilton Depression Rating Scale (HDRS: Hamilton, 1960) and the Extracted Hamilton Depression Rating Scale (XHDRS). Regarding the latter measure in particular, research has shown good internal consistency, interrater reliability, concurrent validity, convergent validity, and discriminant validity. The XHDRS also showed improved specificity and positive predictive power when compared with several widely used self-report symptom scales (Rapp, Smith, & Britt, 1990). Variations and adjunctive procedures for

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use with the Hamilton Scales also exist (e.g., the Montgomery–Åsberg Depression Rating Scale; Montgomery & Asberg, 1979; Williams & Kobak, 2008). Also, several other examiner-completed scales are available to address general behavioral disturbances, often associated with dementia (Cohen-Mansfield & Martin, 2010). These include (a) the Cohen-Mansfield Agitation Inventory (CMAI: Bidzan, Bidzan,  & Pąchalska, 2012; Cohen-Mansfield, 2001; Finkel, Lyons,  & Anderson, 1992); (b)  the CERAD Behavior Rating Scale for Dementia (CBRSD; CERAD, 2005; Mack, Patterson,  & Tariot, 1999; Patterson  & Mack, 1997; Patterson, Mack, Mackell, et  al., 1997; Tariot, 1996); and (c)  the Neuropsychiatric Inventory (NPI) and the Neuropsychiatric Inventory–Nursing Home Version (NPI-NH; Cummings, 1997; Cummings, Mega, Gray, Rosenberg-Thompson, Carusi,  & Gornbein, 1994; Cummings, & McPherson, 2001; Iverson, Hopp, DeWolfe, & Solomons, 2002; Lange, Hopp, & Kang, 2004). The CMAI takes about 20 minutes to complete and includes 29 items designed to evaluate and quantify “agitated” behaviors in nursing home residents. The CBRSD can be completed in about 30 minutes and includes 48 items, providing a detailed elicitation and quantification of a broad range of psychopathology in individuals with mild to moderate dementia (particularly designed for Alzheimer’s type). This latter instrument has been used as an outcome measure in drug trials and may have some utility in tracking an individual’s response to medication targeting dementia. The NPI and NPI-NH can be completed in roughly 20 minutes and include about 10 items in each of six domains, providing assessment and quantification of a variety of symptoms. When questions about the overall “social climate” of the setting arise, instruments such as the Sheltered Care Environment Scale (SCES; Lemke  & Moos, 1990)  are available. This scale was developed primarily to measure social climate as an attribute of a setting. The SCES was designed to maximize differences between settings, while minimizing differences between individuals within a setting. In general, available evidence indicates that the SCES subscales provide reasonably reliable and valid indices of the social climate of group residential facilities.

Projective Tests Although practitioners’ views vary widely regarding their utility (e.g., Lilienfeld, Wood,  & Garb, 2000; Wood, Nezworski,  & Garb, 2003; Wood, Nezworski, Lilienfeld,  & Garb, 2003), projective techniques can be of some use in the LTC setting. For example, they may prove useful in situations where an elderly person lacks test-wise skills and is uncomfortable in answering direct questions (Tuokko & Hadjistavropoulos, 1998). Care must be taken in using such tests, as the influence of comorbid factors such as cognitive impairment must be taken into account in interpretation. For example, projective drawings can be utilized and may be well tolerated, but issues such as visual field defects, unilateral neglect, general constructional apraxia, and other such impairments may greatly complicate straightforward interpretation of the resulting figures. As always, approaches that are most supported by an empirical literature base (regarding administration, scoring, and interpretation) should be selected whenever possible. While some research specific to the use of such tests with the elderly has been done (e.g., Hayslip & Lowman,

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1986), validity evidence remains to be more fully accumulated. The following paragraphs provide some description of the more commonly known projective tests utilized in LTC. The Rorschach Inkblot Test (RIT; Exner, 2005; Exner  & Erdberg, 2005; Groth-Marnat, 2009) might be helpful, for example, when obvious face validity is a concern and/or when the question of the veteran’s response to a less structured situation is in question. That is, the referral question may ask about a veteran’s ability to maintain his or her level of function in a “less structured setting,” such as his or her own apartment, as opposed to the highly structured LTC environment. The RIT provides the opportunity to observe the veteran’s response to a situation with limited structure, and thus may provide relevant information in such a context. The instrument can also provide information about mood, as well as underlying thought disorder (as might be revealed in such things as limited form quality in someone who appears less disturbed on more structured tasks). For a more general discussion regarding assessment for psychosis in the elderly, see Depp, Loughran, Vahia, and Molinari, 2010. Some of the strengths, possible drawbacks, and general controversies over the use of the RIT have been amply discussed in the literature and will not be repeated here (Garb, Wood, Lilienfeld, & Nezworski, 2005; Garb, Wood, Nezworski, Grove, & Stejskal, 2001; Society for Personality Assessment, 2005). The interested reader is referred to Meyer (2001) for a discussion of the general utility of the instrument. While literature addressing the use of the RIT with older institutionalized adults is limited, it has been used with the elderly (e.g., Gross, Newton, & Brooks, 1990; Segal, Coolidge, & Hersen, 1998). The RIT system developed by Exner (2005) appears to be the most well-researched and standardized in terms of administration, scoring, and interpretation. Interestingly, the approach described by Exner (2005) may well limit the “projective” value of the test. That is, the shift away from the associative value of the ink blots, with more of a focus on what the stimulus “looks like,” may lead to less idiosyncratic responses (thus limiting in some ways the projective value). This alteration in focus to some extent emphasizes visual-spatial problem-solving more than projection per se and, thus, the influence of comorbid cognitive impairment must be kept carefully in mind when interpreting the task. Nevertheless, this alteration was necessary in order to create a system that more easily lends itself to research addressing reliability and validity. The Thematic Apperception Test (TAT; Aronow, Altman Weiss,  & Reznikoff, 2001; Groth-Marnat, 2009; Murray, 1973) can also provide some useful information in some situations. While there has been a form developed for older individuals (i.e., the Senior Apperception Test; SAT), questions have been raised about the need for such a version and some of the implications of the situations depicted (Groth-Marnat, 2009). Experience has shown that the TAT is well tolerated (provided adequate eyesight) in LTC and can provide information bearing on such things as an individual’s coping mechanisms, which can be helpful in treatment planning. One particular drawback in LTC appears in the context of cognitive impairment. The standard administration instructions for the TAT essentially request that the individual tell as dramatic a story as he or she can about what is happening in the picture, including what is happening in the moment depicted, what the characters are thinking and feeling, what things led up to this point, and how the story will end.

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Thus, there is some cognitive complexity to the task, and the instructions may need to be repeated frequently to get complete stories. Even so, the record is likely to be so limited as to provide limited information for full interpretation. Of note regarding the use of the TAT is the absence of a generally agreed-upon normative scoring system for responses. The original scoring system devised by Henry Murray is time-consuming and unwieldy, and as a result has been little used by later interpreters. Other scoring systems have since been introduced that focus on one or two specific variables, such as hostility, depression, and object relations. While these systems are more practical for clinical use, they are not generally comprehensive. Thus, caution is urged in use of the TAT, though it can be of some use at times, perhaps in serving as a vehicle for interview in certain situations (Lilienfeld, Wood, & Garb, 2000). COGNITIVE/INTELLIGENCE TESTS When the question of intelligence is pertinent to answering the referral question, the choice of instruments is likely to follow the same considerations as outlined above. The Shipley Institute of Living Scale-2 (SILS-2) is a relatively brief instrument providing an estimate of overall intelligence based on vocabulary and either an abstraction or block design subtest (Shipley, Gruber, Martin, & Klein, 2009). The test can be administered in about 25 minutes and scored in about 10 minutes. Norms are provided up to the age of 89 years. Another means for assessing intelligence based on the well-known Wechsler Scales is the Wechsler Abbreviated Scale of Intelligence-II (WASI-II; Wechsler, 2011). This test may be appropriate for use in a given case, and the manual provides norms for those up to age 90. Also, the Reynolds Intellectual Screening Test (RIST; Kamphaus & Reynolds, 2003) can be used, and the interpretive program provides information relevant to a nursing home setting. The RIST can be completed in about 15 minutes and, importantly, provides norms to age 94 years.

Screens for Mental Status Detailed and excellent reviews of specific cognitive screens are provided elsewhere (e.g., Cullen, O’Neill, Evans, Coen, & Lawlor, 2006; Lengenfelder & DeLuca, 2005; Mast & Gerstenecker, 2010; Mitrushina, 2009; Waldron-Perrine & Bieliauskas, 2012), and a detailed examination of such instruments is beyond the scope of this chapter. It should be noted clearly that ethical considerations and good practice encourage the psychologist or geropsychologist working in LTC to consider referring to neuropsychology when the differential becomes complex or is uncertain. At the very least, it is of critical importance to understand the differences between normal aging, mild cognitive impairment, and dementia (Duff  & Grabowski, 2008; Salthouse, 2010). That said, a few of the more commonly encountered screening tests are covered for the practicing psychologist. One of the most ubiquitous screening instruments in hospital settings is the Mini-Mental State Examination (MMSE; Folstein  & Folstein, 2010; Folstein, Folstein, & McHugh, 2001; Folstein, Folstein, & McHugh, 1975; Folstein, Folstein, White, & Messer, 2010). This measure is administered by a range of clinicians (e.g.,

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psychologists, psychiatrists, geriatricians, internists, neurologists, nurse practitioners, social workers, occupational therapists), so it is a test with which the psychology practitioner in LTC should be familiar. Scores on this screening test run from 0 to 30, with a cutoff score of 24 frequently used in clinical settings to identify impairment. The MMSE takes only a few minutes to administer and score. However, the clinician is cautioned in that the MMSE has somewhat limited reliability and validity (and experience has shown that it is not often given with strict adherence to standard administration), gives only a gross indication of impairment, and has been shown to over-pathologize individuals with limited education or lower than average IQ (Waldron-Perrine & Bieliauskas, 2012; Whitney, Maoz, Hook, Steiner, & Bieliauskas, 2007). While there have been attempts to interpret individual MMSE items diagnostically, psychometric questions about this practice easily could be raised. In addition, the MMSE has been used with less frequency in recent years in VA settings due to copyright issues. Given some of the above considerations regarding the MMSE, use of the Montreal Cognitive Assessment (MoCA:  Nasreddine et  al., 2005; Wong et  al., 2009)  has become increasingly common within VA settings. The MoCA is also scored on a 30-point scale, can be administered in roughly 10 minutes, and can be scored in about 1 minute by an examiner familiar with the instrument. Often, scores of 26 and up are considered within normal limits. This screen can be given at the bedside with a minimum of materials. The MoCA assesses cognition more broadly than the MMSE, providing some coverage of memory, language, and executive functions, and also addresses the question of global deterioration. Several studies have supported the instrument’s psychometric properties (Gill, Freshman, Blender, & Ravina, 2008; Luis, Keegan,  & Mullen, 2009)  and incremental utility over the MMSE (Damian et al., 2011; Waldron-Perrine & Bieliauskas, 2012). Another commonly employed tool in the LTC setting is the Cognistat (Kiernan, Mueller, Langston,  & Van Dyke, 1987; Kiernan, Mueller,  & Langston, 2011), formerly called the Neurobehavioral Cognitive Status Exam. This instrument assesses functioning across 10 cognitive domains and provides a profile of cognitive status across subtests. A screen and metric approach is used in most of the domains (i.e., a challenging item is administered in a particular domain and, if passed, no further items need be administered in that domain), resulting in some efficiency of assessment, though some have noted the lack of strong correlation between the screen item and the resulting score if the items in the metric are administered, suggesting that all the items should be administered. The Cognistat is available in the original paper-and-pencil version and in computerized PDF formats. One very common cognitive screening battery often used by psychologists in LTC settings is the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; Randolph, 2012; Randolph, Tierney, Mohr, & Chase, 1998). This frequently used screening battery has become the core battery for some neuropsychologists working in geriatric settings. The instrument was designed initially to identify and characterize dementia in the elderly. However, subsequent studies have supported its use across a range of the conditions that can be encountered in LTC and elsewhere (Duff, Patton, Schoenberg, Mold, Scott, & Adams, 2003; Gogos, Joshua, & Rossell, 2010; Green, Garrick, Sheedy, Blake, Shores, & Harper, 2010; McKay, Wertheimer, Fichtenberg, & Casey, 2008; Rinehardt et al., 2010).

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The RBANS provides five individual index scores covering a range of cognitive domains, as well as a total cognitive impairment score. Furthermore, normative data are available for each of the individual subtests comprising the indices, which has been a welcome addition (Randolph, 2005), and the 2011 update includes equated forms C and D (expanding on the original forms A and B) as well as Spanish form A. The time needed to administer the RBANS is generally between approximately 35 and 45 minutes, and scoring requires about another half hour (greatly facilitated by using software to score subtests and calculate indices). The alternate forms can aid in serial assessment. Profiles across indices have been identified for various conditions (e.g., Duff, Schoenberg, Mold, Scott, & Adams, 2007assessment of level of effort is possible (Silverberg, Wertheimer, & Fichtenberg, 2007), and interestingly the effort index has been shown to predict treatment group attendance in patients with schizophrenia (Moore, Davine, Harmell, Cardenas, Palmer, & Mausbach, 2013). Some psychologists working in LTC choose to use the Dementia Rating Scale (DRS-2; Jurica, Leitten, & Mattis, 2001; Mattis, 1988). The DRS-2 is a 36-task and 32-stimulus card individually administered instrument designed to assess level of cognitive functioning for individuals with brain dysfunction. The DRS-2 is sensitive at the lower ends of functioning and differentiating levels of deficits. Good psychometric properties have been reported, and the scale provides useful information across a range of domains of function often impacted by dementia. Importantly, norms through 105 years of age are available, supporting the use of this test in LTC.

Challenges to Assessment or Interpretation Given the nature of the setting, assessment may be difficult to schedule, and sessions may be interrupted for a number of reasons. Multiple appointments may be required. Private space may be at a premium in some CLCs, so carrying out an assessment while maintaining confidentiality can be a challenge. The multiple medical problems encountered and difficulties with vision, auditory acuity, stamina, the influence of medications, and medical illnesses themselves are likely to interact to make assessment and interpretation complex (Caplan  & Shechter, 2005; Segal, Coolidge, & Hersen, 1998). While the level of cognitive function may be part of the referral question, neuropsychological impairment itself may complicate the assessment. For example, assessing for the presence of pain across several days may be complicated by the presence of memory problems. Considerations to keep in mind when addressing the important differential of depression and dementia is the observation that depression is likely to influence motor speed, attention, basic encoding of information, and verbal fluency, and these domains are also likely to be affected by dementia processes (Hibbard, Breed, Ashman, & Williams, 2005; Lamberty & Bieliauskas, 1993). However, serial presentation of information and provision of structure have been shown to increase encoding in depression, whereas this is not the case (at least to the same degree) in dementia. Furthermore, in those with depression, there is no accelerated rate of forgetting on delayed recall testing and little decline in expressive or receptive language skills, with the exception of decreased response latency, in contrast to what is encountered in those with dementia (Lamberty & Bieliauskas, 1993; Waldron-Perrine & Bieliauskas, 2012).

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RECOMMENDED PROCEDURES, TESTS, AND BATTERIES Making many specific recommendations for a particular battery would run the risk of oversimplifying practice in the complex venue represented by LTC. However, use of the GDS (including, as appropriate, the standard version, abbreviated version, and collateral version), SILS-2, CASE (or abbreviated forms of the SCL-90-R or MMPI-II), CAGE, MAST-G, and PCL-M (or TSI-2 if necessary to address validity concerns) should be routine. The HDRS or XHRDR may be of help when self-report of mood is not practical. The NPI-NH (or CMAI) should be considered in assessing problematic behaviors. Other instruments may be used supplementally as needed. For example, if other cognitive functions are in question, use of the MoCA or RBANS would be reasonable. Some situations may call for the use of assessment techniques providing less “structure” (e.g., the RIT) when questions arise about such issues as underlying psychotic process, or when the treatment team needs to know how well the veteran might do in a setting with less external constraints (e.g., independent living). It should be reiterated that LTC does not preclude the use of any of the assessment tools available to the mental health professional, but suggestions here may maximize the amount of information obtained while limiting the time needed for evaluation. SAMPLE REPORT The Guidelines and Standards (APA, 2013; APA, 2004) call for psychologists to promote the optimal delivery of their services through effective and timely communication with other healthcare professionals. Considerations include an understanding of the formal and informal means by which information is exchanged and documented, use of language that is understandable to nonpsychologists, operationalizing discipline-specific terms and concepts, including those explicating mind-body issues, and appreciating that the timeliness of communication can determine the degree to which it is perceived as helpful for care. Furthermore, in the CLC and elsewhere, the psychologist should remain aware that veterans may in fact read their own reports and chart notes, calling for the writer to word information in a way that will do no harm and, if possible, may be of therapeutic value to the veteran reader. There is no absolute format for a report in LTC, and the practitioner would do well to attend to the needs of the veterans and specific institutional and referral source considerations. Thus, the example report (see Appendix 3.1) is meant merely as suggestive.

CONCLUSIONS Psychologists in LTC face many challenges and unique opportunities in the psychological assessment of the individuals they serve. Within the VA, psychologists are very commonly found in the LTC setting, opening this important venue for practice including both assessment and intervention. For veterans receiving institutionalized LTC within the VA, service is most often provided in one of the many CLCs. There is a recognized knowledge base that is considered necessary for appropriate practice in such a setting. Of course, psychologists working within VA settings

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also should remain aware of studies with specific relevance to veteran populations and issues (such as research addressing war- and trauma-related syndromes) and VA policy concerning the assessment of conditions often experienced by veterans. Psychologists practicing in LTC should remain aware of the limits of their training and expertise, and should refer elsewhere when questions fall outside their purview (e.g., when questions arise about complex differential diagnoses of dementia, referral to neuropsychology should be considered as appropriate). While the full range of psychological assessment techniques and procedures in the armamentarium of the psychologist could be selected from, given considerations of the setting and the common comorbidities encountered, there are a number of more commonly used and recommended instruments. Although assessing some of the more commonly encountered conditions is the focus of the current chapter, a number of other instruments could be of use in assessing for a more complete range of psychopathological conditions (e.g., personality disorders, hypochondriasis, psychosis, sleep disturbance; Tuokko & Hadjistavropoulos, 1998). An evidence-based approach is likely to provide the most psychometrically rigorous assessment of those served in LTC. An assessment with instruments chosen on the basis of sound psychometric support will likely provide the most useful information to guide treatment planning and intervention. REFERENCES Abeles, N., Cooley, S., Deitch, I.  M., Harper, M.  S., Hinrichsen, G., Lopez, M.  A.,  & Molinari, V.  A. (1998). What practitioners should know about working with older adults. Professional psychology:  Research and practice, 29, 413–427. Retrieved from www.apa.org/pi/aging/practitioners.pdf Alexopoulos, G. A., Abrams, R. C., Young, R. C., & Shamoian, C. A. (1988). Cornell scale for depression in dementia. Biological Psychiatry, 23, 271–284. American Bar Association Commission on Law and Aging & American Psychological Association. (2005). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: Author. American Psychological Association. (1998). Guidelines for the evaluation of dementia and age-related cognitive decline. American Psychologist, 53, 1298–1303. American Psychological Association. (2004). Guidelines for psychological practice with older adults. American Psychologist, 59, 236–260. American Psychological Association. (2013). Guidelines for psychological practice in health care delivery systems. American Psychologist, 68, 1–6. Aronow, E., Altman Weiss, K., & Reznikoff, M. (2001). A Practical guide to the Thematic Apperception Test: The TAT in clinical practice. Philadelphia, PA: Taylor and Francis. Babor, T.  F., de la Fuenta, J.  R., Saunders, J.,  & Grant, M. (1992). The Alcohol Use Disorders Identification Test:  Guidelines for its use in primary health care. Geneva, Switzerland: World Health Organization. Barry, K. L., & Blow, F. C. (2010). Screening, assessing and intervening for alcohol and medication misuse in older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 307–330). London, England:  Academic Press/ Elsevier. Beck, A. T. (1987). Beck Depression Inventory: Manual. San Antonio, TX: Psychological Corporation.

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Beck, A.  T.,  & Steer, R.  A. (1993). Beck Anxiety Inventory manual. San Antonio, TX: Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory, Second Edition (BDI-II). San Antonio, TX: Psychological Association. Bidzan, L., Bidzan, M., Pąchalska, M. (2012). Aggressive and impulsive behavior in Alzheimer’s disease and progression of dementia. Medical Science Monitor: International Medical Journal of Experimental and Clinical Research, 18, 182–189. Blazer, D.  G. (1994). Epidemiology of late-life depression. In L. S.  Schneider, C. F.  Reynolds, B. D.  Lebowitz,  & A. J.  Freidhoff (Eds.), Diagnosis and treatment of depression in late life: Results of the NIH consensus development conference (pp. 9–19). Washington, DC: American Psychiatric Press. Blow, F. C. (Consensus Panel Chair) (1998). Substance use among older adults: Treatment improvement protocol (TIP) Series 26. Rockwall, IL; Rockville, MD: US Department of Health and Human Services, Public Health Service, Substance Abuse and Mental Health Administration, Center for Substance Abuse Treatment. DHHS Publication No. (SMA) 98–3179. Blow, F.  C., Brower, K.  J., Schulenberg, J.  E., Demo-Dananberg, L.  M., Young, J.  P.,  & Beresford, T. P. (1992). The Michigan Alcoholism Screening Test—Geriatric Version (MAST-G):  A  new elderly specific screening instrument. Alcoholism:  Clinical and Experimental Research, 16, 372. Blow, F. C., Cook, C. A., Booth, B. M., Falcon, S. P., & Friedman, M. J. (1992). Age-related psychiatric comorbidities and level of functioning in alcoholic veterans seeking outpatient treatment. Hospital and Community Psychiatry, 43, 990–995. Briere, J. (2010). Trauma Symptom Inventory, 2nd edition (TSI-2) professional manual. Odessa, FL: Psychological Assessment Resources. Brown, C., Schulberg, H. C., & Madonia, M. J. (1995). Assessing depression in primary care practice with the Beck Depression Inventory and the Hamilton Rating Scale for Depression. Psychological Assessment, 7, 59–65. Bruce, M. L., Ten Have, T. R., Reynolds, C. F. III, Katz, I. I., Schulberg, H. C., Mulsant, B.  H., . . . & Alexopoulos, G.  S. (2004). Reducing suicidal ideation and depressive symptoms in depressed older primary care patients: A randomized controlled trial. Journal of the American Medical Association, 291, 1081–1091. Bush, S. S. (Ed.) (2012). Neuropsychological practice with veterans. New York, NY: Springer Publishing Company. Butcher, J. N., Aldwin, C. M., Levenson, M. R., Ben-Porath, Y. S., Sprio, A., & Bosse, R. (1991). Personality and aging: A study of the MMPI-2 among older men. Psychology and Aging, 6, 361–370. Butcher, J.  N., Dahlstrom, W.  G., Graham, J.  R., Tellegen, A.,  & Kraemer, B. (1989). Minnesota Multiphasic Personality Inventory-2 (MMPI-2): Manual for administration and scoring. Minneapolis: University of Minnesota. Caplan, B., & Shechter, J. A. (2005). Test accommodations in geriatric neuropsychology. In S. S. Bush & T. A. Martin (Eds.), Geriatric neuropsychology: Practice essentials (pp. 97–114). New York, NY: Taylor & Francis. Carmin, C., &, Ownby, R.  L. (2010). Assessment of anxiety in older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 45– 60). London, England: Academic Press/Elsevier. Cohen-Mansfield, J. (1991, 2001). Instruction manual for the Cohen-Mansfield Agitation Inventory. Rockville, MD:  The Research Institute of the Hebrew Home of Greater Washington.

72

P sychological A ss e ssm e nt of V e t e rans

Cohen-Mansfield, J., & Martin, L. S. (2010). Assessment of agitation in older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 381–403). London, England: Academic Press/Elsevier. Consortium to Establish a Registry for Alzheimer’s Disease. (2005). CERAD Behavior Rating Scale for Dementia (CBRSD). Retrieved from http://cerad.mc.duke.edu/Scale. htm Cullen, B., O’Neill, B., Evans, J. J., Coen, R. F., & Lawlor, B. A. (2006). A review of screening tests for cognitive impairment. Journal of Neurology, Neurosurgery and Psychiatry, 78, 790–799. Cummings, J. L. (1997). The Neuropsychiatric Inventory: Assessing psychopathology in dementia patients. Neurology, 48(suppl 6), S10–S16. Cummings, J.  L., Mega, M., Gray, K., Rosenberg-Thompson, S., Carusi, D.  A.,  & Gornbein, J. (1994). The neuropsychiatric inventory: Comprehensive assessment of psychopathology in dementia. Neurology, 44, 2308–2314. Cummings, J. L., & McPherson, S. (2001). Neuropsychiatric assessment of Alzheimer’s disease and related dementias. Aging, 13, 240–246. Dahlstrom, W. G., Welsh, G. S., & Dahlstrom, L. E. (1972). An MMPI handbook: Volume 1. A clinical interpretation (rev. ed). Minneapolis: University of Minnesota Press. Damian, A. M., Jacobson, S. A., Hentz, J. G., Belden, C. M., Shill, H. A., Sabbagh, M. N., & Adler, C. H. (2011). The Montreal Cognitive Assessment and the Mini Mental State Exam as screening instruments for cognitive impairment: Item analyses and threshold scores. Dementia and Geriatric Cognitive Disorders, 31, 126–131. Department of Veterans Affairs, Veterans Health Administration. (2013). VHA Handbook 1142.03:  Requirements for the use of the Resident Assessment Instrument (RAI) Minimum Data Set (MDS). Washington, DC:  Author. Retrieved from http:// www.mirecc.va.gov/VISN16/docs/UMHS_Handbook_1160.pdf Department of Veterans Affairs. (2012). 2012 VHA facility quality and safety report. Washington, DC: Department of Veterans Affairs, Office of Quality, Safety and Value. Department of Veterans Affairs, Veterans Health Administration. (2008). VHA Handbook 1160.01: Uniform mental health services in VA medical centers and clinics. Washington, DC: Author. Depp, C. A., Loughran, C., Vahia, I., & Molinari, V. (2010). Assessing psychosis in acute and chronic mentally ill older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 123–154). London, England:  Academic Press/Elsevier. Derogatis, L. R. (1977). The SCL-90 Manual I: Scoring, administration, and procedures for the SCL-90. Baltimore, MD: Johns Hopkins University School of Medicine, Clinical Psychometrics Unit. Division 20, American Psychological Association. (2000, April). Training guidelines for practice in clinical geropsychology (Draft #8)[On-Line]. Retrieved from http://aging. ufl.edu/apadiv20/qualtf8b.htm Drexler, M.  L.,  & Walker, W. (2003). Geropsychology:  Emerging practice and training. In M. B.  Kenkel, L. Winfrey, L. Collins,  & J. Yalof (Prog. Committee), NCSPP pre-conference book of readings. Washington, DC: American Psychological Association. Retrieved from http://www.ncspp.info/drexler.PDF Duff, K.,  & Grabowski, T.  J. (2008). Normal aging, mild cognitive impairment, and dementia. In A. M. Horton, Jr., & D. Wedding (Eds.), The neuropsychology handbook (3rd ed., pp. 571–602). New York: Springer Publishing.

Long-Term Care

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Duff, K., Patton, D., Schoenberg, M. R., Mold, J., Scott, J. G., & Adams, R. (2003). Ageand education-corrected independently normative data for the RBANS in a community dwelling elderly sample. The Clinical Neuropsychologist, 17, 351–366. Duff, K., Schoenberg, M. R., Mold, J. W., Scott, J. G., & Adams, R. L. (2007). Normative and retest data on the RBANS cortical/subcortical index in older adults. Journal of clinical and experimental neuropsychology, 29(8), 854–859. Edelstein, B. A., Drozdick, L. W., & Ciliberti, C. M. (2010). Assessment of depression and bereavement in older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 3–43). London, England: Academic Press/Elsevier. Edelstein, B. A., & Segal, D. L. (2011). Assessment of emotional and personality disorders in older adults. In K. W. Schaie & S. L. Willis (2011), Handbook of the psychology of aging (7th ed., pp. 325–337). Burlington, MA: Academic Press/Elsevier. Ewing, J.  A. (1984). Detecting alcoholism:  The CAGE questionnaire. Journal of the American Medical Association, 252, 1905–1907. Exner, J. (2005). A Rorschach workbook for the Comprehensive System (5th ed.) Asheville, NC: Rorschach Workshops. Exner, J., & Erdberg, P. (2005). The Rorschach: A Comprehensive System. Vol. II (3rd ed.). Hoboken, NJ: Wiley & Sons. Finkel, S.  I., Lyons, J.  S.,  & Anderson, R.  L. (1992). Reliability and validity of the Cohen-Mansfield Agitation Inventory in institutionalized elderly. International Journal of Geriatric Psychiatry, 7, 487–490. Fitten, L.  J., Lusky, R.,  & Hamann, C. (1990). Assessing treatment decision-making capacity in elderly nursing home residents. Journal of the American Geriatrics Society, 38, 1097–1104. Folstein, M. F., & Folstein, S. E. (2010). Mini-Mental® State Examination, 2nd Edition™ (MMSE®-2™). Lutz, FL: Psychological Assessment Resources. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). “Mini-mental state”: A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (2001). Mini-Mental State Examination. Lutz, FL: Psychological Assessment Resources. Folstein, M.  F., Folstein, S.  E., White, T.,  & Messer, M.  A. (2010). Mini-Mental® State Examination, 2nd Edition™ (MMSE®-2™):  User’s Manual. Lutz, FL:  Psychological Assessment Resources. Gaylord, K. M. (2006). The psychosocial effects of combat: The frequently unseen injury. Critical Care Nursing Clinics of North America, 18, 349–357. Gallagher, D. (1986a). Assessment of depression by interview methods and by psychiatric rating scales. In L. W. Poon (Ed.), Handbook for clinical memory assessment of older adults (pp. 202–212). Washington, DC: American Psychological Association. Gallagher, D. (1986b). The Beck Depression Inventory and older adults:  Review of its development and utility. Clinical Gerontologist, 5, 149–163. Garb, H.  N., Wood, J.  M., Lilienfeld, S.  O.,  & Nezworski, M.  T. (2005). Roots of the Rorschach controversy. Clinical Psychology Review, 25(1), 97–118. Garb, H. N., Wood, J. M., Nezworski, M. T., Grove, W. M., & Stejskal, W. J. (2001). Toward a resolution of the Rorschach controversy. Psychological Assessment, 13, 433–448. Gill, D.  J., Freshman, A., Blender, J.  A.,  & Ravina, B. (2008). The Montreal Cognitive Assessment as a screening tool for cognitive impairment in Parkinson’s disease. Movement Disorders, 23, 1054–1056.

74

P sychological A ss e ssm e nt of V e t e rans

Gogos, A., Joshua, N.,  & Rossell, S.  L. (2010). Use of the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) to investigate group and gender differences in schizophrenia and bipolar disorder. Australia and New Zealand Journal of Psychiatry, 44, 220–229. Graham, J.  R. (1993). MMPI-2:  Assessing personality and psychopathology (2nd ed.). New York, NY: Oxford University Press. Greene, R. L. (2011). The MMPI-2/MMPI-2-RF: An interpretive manual (3rd ed.). San Antonio, TX: Pearson Assessments. Greene, R. L. (1980). The MMPI: An interpretive Guide (2nd ed.). New York: Grune & Stratton. Green, A., Garrick, T., Sheedy, D., Blake, H., Shores, E. A., & Harper, C. (2010). The effect of moderate to heavy alcohol consumption on neuropsychological performance as measured by the Repeatable Battery for the Assessment of Neuropsychological Status. Alcohol Clinical and Experimental Research, 34, 443–450. Grisso, T. (1994). Clinical assessments for legal competence of older adults. In M. Storandt & G. R. VandenBos (Eds.), Neuropsychological assessment of dementia and depression in older adults: A clinician’s guide (pp. 119–140). Washington, DC: American Psychological Association. Gross, A., Newton, R. R., & Brooks, R. B. (1990). Rorschach responses in healthy, community dwelling older adults. Journal of Personality Assessment, 55, 335–343. Groth-Marnat, G. (2009). Handbook of psychological assessment (5th ed.). Hoboken, NJ: John Wiley & Sons. Hale, W. D., Cochran, C. D., & Hedgepeth, B. E. (1984). Norms for the Brief Symptom Inventory. Journal of Consulting and Clinical Psychology, 52, 321–322. Hall, E., Hategan, A., & Bourgeois, J. A. (2012). Borderline personality disorder in residential care facilities. Annals of Long-Term Care: Clinical Care and Aging, 20, 34–38. Hamilton, M. (1960). A rating scale for depression. Journal of Neurology, Neurosurgery and Psychiatry, 23, 56–62. Hayslip, B., & Lowman, R. L. (1986). The clinical use of projective techniques with the aged: A critical review and synthesis. Clinical Gerontologist, 5, 63–94. Hibbard, M. R., Breed, S., Ashman, T., & Williams, J. (2005). Co-occurring psychiatric and neurological impairments in older adults. In S. S. Bush & T. A. Martin (Eds.), Geriatric neuropsychology: Practice essentials (pp. 327–362). New York, NY: Taylor & Francis. Himelick, A.,  & Walsh, J. (2002). Nursing home residents with borderline personality traits:  Clinical social work interventions. Journal of Gerontological Social Work, 37, 49–63. Hunsley, J., & Mash, E. J. (2010). The role of assessment in evidence-based practice. In M. M. Anthony & D. H. Barlow (Eds.), Handbook of assessment and treatment planning for psychological disorders (2nd ed., pp. 3–22). New York, NY: The Guilford Press. Iverson, G. L., Hopp, G. A., DeWolfe, K., & Solomons, K. (2002). Measuring change in psychiatric symptoms using the Neuropsychiatric Inventory: Nursing Home version. International Journal of Geriatric Psychiatry, 17, 438–443. Jurica, P. J., Leitten, C. L., & Mattis, S. (2001). Dementia Rating Scale-2 professional manual. Lutz, FL: Psychological Assessment Resources. Kamphaus, R. W., & Reynolds, C. R. (2003). Reynolds Intellectual Screening Test (RIST). Lutz, FL: Psychological Assessment Resources. Kiernan, R.  J., Mueller, J.,  & Langston, J.  W. (2011). Cognistat  & Cognistat Assessment Manual. Lutz, FL: Psychological Assessment Resources.

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Kiernan, R. J., Mueller, J., Langston, J. W., & Van Dyke, C. (1987). The Neurobehavioral Cognitive Status Examination: A brief but differential approach to cognitive assessment. Annals of Internal Medicine, 107, 481–485. Knight, R. G., Waal-Manning, H. A., & Spears, G. F. (1983). Some norms and reliability data for the State-Trait Anxiety Inventory and the Zung Self Rating Depression Scale. British Journal of Clinical Psychology, 22, 245–249. Koehler, M., Rabinowitz, T., Hirdes, J., Stones, M., Carpenter, G. I., Fries B. E., . . . & Jones, R.  N. (2005). Measuring depression in nursing home residents with the MDS and GDS: An observational psychometric study. BMC Geriatrics, 5, 1–8. Koenig, H. G., Meador, K. G., Cohen, H. J., & Blazer, D. G. (1988). Depression in elderly hospitalized patients with medical illness. Archives of Internal Medicine, 148, 1929–1936. Kurlowicz, L.  H., Evans, L.  K., Strumpf, N.  E.,  & Maislin, G. (2002). A psychometric evaluation of the Cornell Scale for Depression in Dementia in a frail, nursing home population. American Journal of Geriatric Psychiatry, 10, 600–608. Lamberty, G.  J.,  & Bieliauskas, L.  A. (1993). Distinguishing between depression and dementia in the elderly: A review of neuropsychological findings. Archives of Clinical Neuropsychology, 8, 149–170. Lange, R. T., Hopp, G. A., & Kang, N. (2004). Psychometric properties and factor structure of the Neuropsychiatric Inventory Nursing Home version in an elderly neuropsychiatric population. International Journal of Geriatric Psychiatry, 19, 440–448. Lawton, M. P., Whelihan, W. M., & Lesher, E. L. (1985). Assessment and intervention by rehabilitation psychology in long-term care. Rehabilitation Psychology, 30, 71–82. Lesher, E. L. (1986). Validation of the Geriatric Depression Scale among nursing home residents. Clinical Gerontologist, 4, 21–28. Lemke, S.,  & Moos, R.  H. (1990). Validity of the Sheltered Care Environment Scale: Conceptual and methodological issues. Psychology and Aging, 5, 569–571. Lengenfelder, J., & DeLuca, J. (2005). Selection and use of screening measures in geriatric neuropsychology. In S. S.  Bush  & T. A.  Martin (Eds.), Geriatric neuropsychology: Practice essentials (pp. 21–40). New York, NY: Taylor & Francis. Lichtenberg, P.  A. (2010). Handbook of assessment in clinical gerontology (2nd ed.). London, England: Academic Press/Elsevier. Lichtenburg, P.  A. (1998). Mental health practice in geriatric health care settings. Binghamton, NY: The Hayworth Press. Lichtenburg, P.  A. (1994). A guide to psychological practice in geriatric long-term care. Binghamton, NY: The Hayworth Press. Lichtenberg, P.  A., Smith, M., Frazer, D., Molinari, V., Rosowsky, E., Crose, R., . . . & Gallagher-Thompson, D. (1998). Standards for psychological services in long-term care facilities. The Gerontologist, 38, 122–127. Lilienfeld, S., Wood, J., & Garb, H. (2000). The status of projective techniques. Psychological Science in the Public Interest, 1, 27–66. Luis, C. A., Keegan, A. P., & Mullen, M. (2009). Cross validation of the Montreal Cognitive Assessment in community dwelling older adults residing in the Southeastern US. International Journal of Geriatric Psychiatry, 24, 197–201. Mack, J.  L., Patterson, M.  B.,  & Tariot, P.  N. (1999). Behavior Rating Scale for Dementia:  Development of test scales and presentation of data for 555 individuals with disease. Journal of Geriatric Psychiatry and Neurology, 12, 211–223. Malmstrom, T. K., & Tait, R. C. (2010). Pain assessment and management in older adults. In P. A. Lichtenberg, Handbook of assessment in clinical gerontology (2nd ed., pp. 581– 618). London, England: Academic Press/Elsevier.

76

P sychological A ss e ssm e nt of V e t e rans

Mast, B.  T.,  & Gerstenecker, A. (2010). Screening instruments and brief batteries for dementia. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 503–530). London, England: Academic Press/Elsevier. Mattis, S. (1988). Dementia Rating Scale: Professional manual. Odessa, FL: Psychological Assessment Resources. McGivney, S. A., Mulvihill, M., & Taylor, B. (1994). Validating the GDS depression screen in the nursing home. Journal of the American Geriatrics Society, 42, 490–492. McKay, C., Wertheimer, J. C., Fichtenberg, N. L., & Casey, J. E. (2008). The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): Clinical utility in a traumatic brain injury sample. The Clinical Neuropsychologist, 22, 228–241. Meyer, G. J. (2001). Special Section: II. The Utility of the Rorschach in Clinical Assessment. Psychological Assessment, 13, 419–422. Meyer, G. J., Finn, S. E., Eyde, L. D., Kay, G. G., Moreland, K. L., Dies, R. R., . . . & Reed, G. M. (2001). Psychological testing and psychological assessment: A review of evidence and issues. American Psychologist, 56, 128–165. Mitrushina, M. (2009). Cognitive screening methods. In I. Grant & K. M. Adams (Eds.), Neuropsychological assessment of neuropsychiatric and neuromedical disorders (3rd ed., pp. 101–121). New York, NY: Oxford University Press. Molinari, V. (Ed.) (2010). Specialty competencies in geropsychology. New York, NY: Oxford University Press. Molinari, V. (2003). Nursing homes as primary care sites for psychological practice. Clinical Psychology: Science and Practice, 10, 112–114. Molinari, V. (Ed.) (2000). Professional psychology in long term care:  A  comprehensive guide. Long Island City, NY: Hatherleigh. Montgomery, S. A., & Asberg, M. (1979). A new depression scale designed to be sensitive to change. British Journal of Psychiatry, 134, 382–389. Montorio, I., & Izal, I. (1996). The Geriatric Depression Scale: A review of its development and utility. International Psychogeriatrics, 8, 103–112. Moore, R. C., Davine, T., Harmell, A. L., Cardenas, V., Palmer, B. W., & Mausbach, B. T. (2013). Using the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) Effort Index to predict treatment group attendance in patients with schizophrenia. Journal of the International Neuropsychological Society, 19, 198–205. Morgan, J.  E. (2002). Ethical issues in the practice of geriatric neuropsychology. In S. S. Bush & M. L. Drexler (Eds.), Ethical issues in clinical neuropsychology (pp. 87–101). Lisse, The Netherlands: Swets & Zeitlinger. Morin, C. M., Landreville, P., Colecchi, C., McDonald, K., Stone, J., & Ling, W. (1999). The Beck Anxiety Inventory:  Psychometric properties with older adults. Journal of Clinical Geropsychology, 5, 19–29. Moye, J. (1996). Theoretical frameworks for competency in cognitively impaired elderly adults. Journal of Aging Studies, 10, 27–42. Moye, J.,  & Braun, M. (2010). Assessment of capacity. In P. A.  Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 581–618). London, England: Academic Press/Elsevier. Murray, H. (1973). The analysis of fantasy. Huntington, NY: Robert E. Krieger. Nasreddine, Z. S., Phillips, N. A., Bedirian, V., Charbonneau, S., Whitehead, V., Collin, I., Chertkow, H. (2005). The Montreal Cognitive Assessment: MoCA: A brief screening tool for mild cognitive impairment. Journal of the American Geriatric Society, 53, 695–699.

Long-Term Care

77

Nesselroade, J.  R., Mitteness, L.  S.,  & Thompson, L.  K. (1984). Older adulthood:  Short term changes in anxiety, fatigue, and other psychological states. Research on Aging, 6, 3–28. Nitcher, R. L., Burke, W. J., Roccaforte, W. H., & Wengel, S. P. (1993). A collateral source version of the Geriatric Depression Rating Scale. American Journal of Geriatric Psychiatry, 1, 143–152. Norris, M., Molinari, V.,  & Ogland-Hand, S. (Eds.) (2002). Emerging practices for psychologists in long term care. Binghamton, NY: Haworth Press. Olin, J.  T., Schneider, L.  S., Eaton, E.  M., Zemansky, M.  F.,  & Pollock, V.  E. (1992). The Geriatric Depression Scale and the Beck Depression Inventory as screening instruments in an older adult outpatient population. Psychological Assessment, 2, 190–192. Oltmanns, T. F., & Balsis, S. (2010). Assessment of personality disorders in older adults. In P. A. Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 101–122). London, England: Academic Press/Elsevier. Pachana, N. A., Burane, G. J., Siddle, H., Koloski, N., Harley, E., & Arnold, E. (2007). Development and validation of the Geriatric Anxiety Inventory. International Psychogeriatrics, 19, 103–114. Parmelee, P. A., Katz, I. R., & Lawton, M. P. (1989). Depression among institutionalized aged: Assessment and prevalence estimation. Journal of Gerontology: Medical Science, 44, M22–M29. Parmelee, P.  A., Lawton, M.  P.,  & Katz, I.  R. (1989). Psychometric properties of the Geriatric Depression Scale among the institutionalized aged. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 1, 331–338. Patterson, M.  B.,  & Mack, J.  L. (1997). CERAD Behavioral Rating Scale for Dementia (BRSD). Alzheimer’s Disease and Associated Disorders, 11, S40–S44. Patterson, M.  B., Mack, J.  L., Mackell, J.  A., Thomas, R., Tariot, P., Weiner, M.,  & Whitehouse, P. J. (1997). A longitudinal study of behavioral pathology across five levels of dementia severity in Alzheimer’s disease: The CERAD Behavior Rating Scale for Dementia. Alzheimer’s Disease and Associated Disorders, 11, S40–S44. Patterson, R.  L., O’Sullivan, M.  J.,  & Spielberger, C.  D. (1980). Measurement of state and trait anxiety in elderly mental health clients. Journal of Behavioral Assessment, 2, 89–97. Priest, W.,  & Meunier, G.  F. (1993). MMPI-2 performance of elderly women. Clinical Gerontologist, 14, 3–11. Kimerling, R., Prins, A., Yeager, D. E., & Magruder, K. M. (2010, November). An interval approach to screening for PTSD in primary care. Poster presented at the 44th annual conference of the Association for Cognitive and Behavior Therapy, San Francisco, CA. Qualls, S. H., Segal, D. L., Norman, S., Niederehe, G., & Gallagher-Thompson, D. (2002). Psychologists in practice with older adults: Current patterns, sources of training, and need for continuing education. Professional Psychology:  Research and Practice, 33, 435–445. Raddloff, L. S. (1977). The CES-D Scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385–401. Randolph, C. (1998). RBANS Manual:  Repeatable Battery for the Assessment of Neuropsychological Status. San Antonio, TX: Psychological Corporation. Randolph, C. (Post-publication date 2005). RBANS: Repeatable Battery for the Assessment of Neuropsychological Assessment—Technical Report #1. Available from the author.

78

P sychological A ss e ssm e nt of V e t e rans

Randolph, C. (2012). Repeatable Battery for the Assessment of Neuropsychological Status Update. Retrieved from www.pearsonassessments.com/HAIWEB/Cultures/en-us/ Productdetail.htm?Pid=RBANS_UPDATE&Mode=summary Randolph, C., Tierney, M. C., Mohr, E., & Chase, T. N. (1998). The Repeatable Battery for the Assessment of Neuropsychological Status (RBANS): Preliminary clinical validity. Journal of Clinical and Experimental Neuropsychology, 20, 310–319. Rankin, E., Gfeller, J. D., & Gilner, F. H. (1993). Measuring anxiety states in the elderly using the State-Trait Anxiety Inventory for Children. Journal of Psychiatric Research, 27, 111–117. Rapp, S. R., Smith, S. S., & Britt, M. (1990). Identifying co-morbid depression in elderly medical patients: Use of the Extracted Hamilton Depression Rating Scale. Psychological Assessment: A Journal of Consulting and Clinical Psychology, 2, 243–247. Reiss, N.  S.,  & Tishler, C.  L. (2008a). Suicidality in nursing home residents:  Part  1. Prevalence, risk factors, methods, assessment and management. Professional Psychology: Research and Practice, 39, 264–270. Reiss, N. S., & Tishler, C. L. (2008b). Suicidality in nursing home residents: Part II. Special issues. Professional Psychology: Research and Practice, 39, 271–275. Reynolds, C.  R.,  & Bigler, E.  D. (2001). Clinical assessment scales for the elderly. Lutz, FL: Psychological Assessment Resources. Richardson, C.,  & Waldrop, J. (2003). Veterans 2000:  Census 2000 brief. Washington, DC: U.S. Census Bureau. Rinehardt, E., Duff, K., Schoenberg, M., Mattingly, M., Bharucha, K., & Scott, J. (2010). Cognitive change on the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS) in Parkinson’s disease with and without bilateral subthalamic nucleus deep brain stimulation surgery. The Clinical Neuropsychologist, 24, 1339–1354. Rosowsky, E., & Gurian, B. (1992). Impact of borderline personality disorder in late life on systems of care. Hospital and Community Psychiatry, 43, 386–389. Salthouse, T. A. (2010). Selective review of cognitive aging. Journal of the International Neuropsychological Society, 16, 754–760. Schonfeld, L, King-Kallimanis, B., Brown, L. M., Davis, D. M., Kearns, W. D., Molinari, V. A., . . . & Nelson, A. L. (2007). Wanderers with cognitive impairment in Department of Veterans Affairs Nursing Home Care Units. Journal of the American Geriatrics Society, 55, 692–699. Scocco, P., Fantoni, G., Rapattoni, M., de Girolamo, G., & Pavan, L. (2009). Death ideas, suicidal thoughts, and plans among nursing home residents. Journal of Geriatric Psychiatry and Neurology, 22(2), 141–148. Segal, D. L., Coolidge, F. L., & Hersen, M. (1998). Psychological testing of older people. In I. H. Nordhus, G. R. VandenBos, S. Berg, & P. Fromholt (Eds.), Clinical Geropsychology (pp. 231–257). Washington, DC: American Psychological Association. Sheikh, J. I., & Yesavage, J. A. (1986). Geriatric Depression Scale (GDS): Recent evidence and development of a shorter version. Clinical Gerontologist, 5, 165–173. Shipley, W.  C., Gruber, C.  P., Martin, T.  A.,  & Klein, A.  M. (2009). Shipley-2. Lutz, FL: Psychological Assessment Resources. Silverberg, N. D., Wertheimer, J. C., & Fichtenberg, N. L. (2007). An effort index for the Repeatable Battery for the Assessment of Neuropsychological Status (RBANS). The Clinical Neuropsychologist, 21(5), 841–854. Smith, L. W., Patterson, T. L., Grant, I., & Clopton, C. (1989). A shortened MMPI useful for psychiatric screening of the non-institutionalized elderly. Journal of Clinical Psychology, 45, 359–365.

Long-Term Care

79

Society for Personality Assessment. (2005). The status of the Rorschach in clinical and forensic practice:  An official statement by the board of trustees of the Society for Personality Assessment. Journal of Personality Assessment, 85, 219–237. Spielberger, C. D., Gorsuch, R. L., & Lushene, R. E. (1970). Manual for the State-Trait Anxiety Inventory. Palo Alto, CA: Consulting Psychologists Press. Spielberger, C.  D., Gorsuch, R.  L., Lushene, R.  E., Montouri, J.,  & Platsek, D. (1973). Preliminary manual for the State-Trait Anxiety Inventory for Children. Palo Alto, CA: Consulting Psychologists Press. Spitzer, R. L., & Endicott, J. (1978). NIMH clinical research collaborative program on the psychobiology of depression: Schedule for Affective Disorders and Schizophrenia (SADS). New York, NY: New York State Psychiatric Institute, Biometrics Research Division. Tariot, P.  N. (1996). CERAD Behavior Rating Scale for Dementia. International Psychogeriatrics, 8(suppl. 3), 317–320. Teresi, J., Abrams, R., Holmes, D., Ramirez, M., & Eimicke, J. (2001). Prevalence of depression and depression recognition in nursing homes. Social Psychiatry and Psychiatric Epidemiology, 36, 613–620. Tuokko, H., & Hadjistavropoulos, T. (1998). As assessment guide to geriatric neuropsychology. Mahwah, NJ: Lawrence Erlbaum Associates. Waldron-Perrine, B.,  & Bieliauskas, L.  A. (2012). Neuropsychological assessment methods and procedures:  Inpatient and outpatient Veterans Affairs settings. In S. S. Bush (Ed.), Neuropsychological practice with veterans (pp. 3–26). New York, NY: Springer. Weathers, F. W., Litz, B. T., Keane, T. M., Herman, D. S., Steinberg, H. R., Huska, J. A., & Kraemer, H.  C. (1996). The utility of the SCL-90-R for the diagnosis of war-zone related posttraumatic stress disorder. Journal of Traumatic Stress, 9, 111–128. Wechsler, D. (2011). Wechsler Abbreviated Scale of Intelligence, Second Edition (WASI-II). San Antonio, TX: Pearson Assessments. Wetherell, J.  L.,  & Areán, P.  A. (1997). Psychometric evaluation of the Beck Anxiety Inventory with older medical patients. Psychological Assessment, 9, 136–144. Wetherell, J. L., & Gatz, M. (2005). The Beck Depression Inventory in older adults with generalized anxiety disorder. Journal of Psychopathology and Behavioral Assessment, 27, 17–24. Whitney, K.  A., Maoz, O., Hook, J.  N., Steiner, A.  R.,  & Bieliauskas, L.  A. (2007). IQ and score on the Mini-Mental State Exam (MMSE): Controlling for effort and education among geriatric inpatients. Neuropsychology Development and Cognition B Aging, Neuropsychology and Cognition, 14, 545–552. Williams, J. B. W., & Kobak, K. A. (2008). Development and reliability of a structured interview guide for the Montgomery-Asberg Depression Rating Scale (SIGMA). The British Journal of Psychiatry, 192, 52–58. Wong, A., Xiong, Y. Y., Kwan, P. W., Chan, A. Y., Lam, W. W., Wang, K., & Mok, V. C. T. (2009). The validity, reliability, and clinical utility of the Hong Kong-Montreal Cognitive Assessment (HK-MoCA) in patients with cerebral small vessel disease. Dementia and Geriatric Cognitive Disorders, 28, 81–87. Wood, J. M., Nezworski, M. T., & Garb, H. N. (2003). Focus on empirically supported methods: What’s right with the Rorschach? Scientific Review of Mental Health Practice, 2, 142–146. Wood, J.  M., Nezworski, M.  T., Lilienfeld, S.  O.,  & Garb, H.  N. (2003). What’s wrong with the Rorschach? Science confronts the controversial inkblot test. San Francisco, CA: Jossey-Bass.

80

P sychological A ss e ssm e nt of V e t e rans

Woodard, J.  L. (2010). Geriatric neuropsychological assessment. In P. A.  Lichtenberg (Ed.), Handbook of assessment in clinical gerontology (2nd ed., pp. 461–501). London, England: Academic Press/Elsevier. Yarvis, J. S., Yoon, E., Amenuke, M., Simien-Turner, S., & Landers, G. D. (2012). Assessment of PTSD in older veterans:  The Posttraumatic Stress Disorder Checklist:  Military Version (PCL-M). Advances in Social Work, 13, 185–202. Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V., Adey, M., & Leirer, V. O. (1982–1983). Development and validation of a geriatric depression screening scale: A preliminary report. Journal of Psychiatric Research, 17, 37–49. Zung, W.  K. (1971). A rating instrument for anxiety disorders. Psychosomatics, 12, 371–379. Zung, W.  K.,  & Green, R.  L. (1973). Detection of affective disorders in the aged. In C. Eisdorfer  & W. E.  Fann (Eds.), Psychopharmacology and aging (pp. 213–223). New York, NY: Plenum Press. Zung, W. W. K., & Zung, E. M. (1986). Use of the Zung Self-Rating Depression Scale in the elderly. Clinical Gerontologist, 5, 137–148.

Appendix 3.1 Example of Psychological Assessment Report in Long-Term Care

REPORT OF PSYCHOLOGICAL CONSULTATION Date

Reason for Referral Mr. Veteran is a 75-year-old right-handed, single, Caucasian male who was referred by Dr. White for psychological evaluation at the request of the interdisciplinary team. Specifically, the treatment team has concerns about the veteran’s mood and cognitive function. He has been seen as “withdrawn, uninterested, and sullen” and, although he is diabetic, he has not been following the diet recommended by the team. The team reports that a Geriatric Depression Scale, Short Version, was administered by Social Work upon admission, and the veteran’s score was 6 (suggesting, at the very least, additional follow-up to evaluate for a diagnosis of depression).

History Mr. Veteran was admitted to the CLC approximately 2 months ago, following a stay of 3 weeks in the acute medical ward as he recovered from hip replacement surgery. He is currently undergoing subacute rehabilitation for ambulation, and the team also has begun to question whether he will be able to return to independent living. Mr. Veteran reported that sleeping has been difficult since he has come into the CLC, and that he has not been eating because he prefers “burgers and fries,” which are seldom served. He has been ordering out and having food delivered. He said, “I have to have something sweet” when asked about his blood sugars. Upon discussion, it was discovered that he is fully aware of the recommended diet, but feels that he might as well eat what he wants at this point. By this, he explained that he believes he is unlikely to recover from his hip surgery. He reported feeling that staff working with him in the CLC are much younger than he, and he believes it is difficult for them to understand his situation (when asked why he does not feel like following through on diet recommendations, despite knowing the benefits and possible consequences of his approach to diet). However, he indicated that he might be open to trying some diabetic candy if this could be made available to him.

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Mr. Veteran stated that one of the things he misses most since coming to the hospital is being able to take a walk outside. He reported that he had always enjoyed taking long and solitary walks, but he had done so less and less as his hip began to bother him. He says he stayed in good physical condition by being able to walk.

Medical History and Medications Mr. Veteran reported being kicked repeatedly in the face (by another child) in a playground fight when he was a child, with loss of consciousness for several hours. CPRS information reveals that Mr. Veteran was evaluated by neurology to address the concerns about his cognitive function. The results were seen as “inconsistent, but not clearly suggestive of any deteriorating condition.” Current medical diagnoses include: Diabetes Type II; Obesity; Osteoarthritis, bilateral hands and knees; Status Post Hip Replacement Surgery, Right Side; Osteoporosis; Amblyopia; Ideopathic Peripheral Neuropathy (with associated pain in fingers and toes); Dry Eyes; Dry Skin; BPH; and Hypertension, nos. His blood sugars are variable, but most often high. His effort in PT has been seen as “variable at best.” Medications at the time of testing included: Glipizide, 10 mg, 2 tablets orally twice per day, 30 minutes before breakfast and lunch, for blood sugar; Gabapentin, 300 mg, 2 capsules orally every morning, and 3 capsules every evening, for pain associated with peripheral neuropathy; Atenolol, 25, 1 tablet daily, hold for SBP less than 100, HR less than 60, for hypertension; Trazodone, 50 mg, 1 tablet at bedtime as needed for sleep; and Finasteride, 5 mg, daily for prostate. The record indicates that Mr. Veteran has been using his medication as prescribed. There is no indication in recent notes from pharmacy, nursing, or medicine to suggest serious side effects, though the veteran has complained of constipation at times.

Education History Mr. Veteran recalled doing well in school in early grades, but had much less success after the head trauma described above (repeating two grades). He said he felt school was like a prison and that he was terrified of showing his report card to his parents. Nevertheless, he graduated and then joined the service. After he left the service at the age of 39, he attempted to return to school. He completed about 1 year of junior college but dropped out as he was “making no progress, only getting discouraged.” He saw a counselor at the college for about 4 sessions, but ended that when he stopped going to school. He denied other contact with mental health professionals.

Military History Mr. Veteran entered the Army at the age of 19 and remained in the service for approximately 20 years. He worked in various capacities while in the service, such as helping with supplies, working in the motor pool, and working in meal preparation, but he never performed particularly well so he was often transferred or given other jobs. He reportedly left the military as an E3, despite having been in the service for nearly two decades. Nevertheless, he denied ever being reduced in rank, and reported that his discharge was honorable. Of note, he said he served in Vietnam for nearly a year. While he denied combat experience per se, he reported being in a bar in Saigon when an explosive device

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went off. He was sitting behind a large pillar so he was knocked off his chair but was essentially uninjured. However, he remembers being surrounded by injured and some dead individuals, including a woman he said he had begun to see socially. This was quite devastating to him, and he remembers feeling “like God abandoned all of us that day, maybe I did something wrong when I met with her?”

Employment History Mr. Veteran reported that following his military service he worked in the automotive industry for about 15 years at various plants and service stations across Michigan. He then worked at various steel mills until he retired on disability at the age of 62. He suffered an injury to his lower back when a tire that was being inflated exploded behind him, causing him to be struck across the back by a tire iron and twisting him as he was thrown into a wall. He reported that over the years he had quit or was fired from many jobs (his estimate was actually 75 jobs). He reported that he never performed quickly enough on the job, and he did not really fit in with the other employees. He denied altercations per se, but said that others on the job “just didn’t like me and I didn’t fit in so I was fired.”

Social History Mr. Veteran reported considerable abuse and neglect growing up as the middle of 9 children, and indicated that it is believed that he was the offspring of a violent sexual encounter between his mother and the brother of the man he considered his father. Mr. Veteran reported that he never felt like he fit in at home, and that he was not wanted by either of his parents. He reported that he had trouble walking until the age of 2 due to “a problem with calcium deficiency,” and that he seldom played with the other children, preferring solitary pursuits. Mr. Veteran reported that one of his biggest concerns has always been his lack of social and occupational achievement, specifically feeling “empty and unsuccessful without more of a career, home, family, and wife.” He has dated and has had some relationships which have lasted several months at a time, but reported fear of intimacy and difficulty with trust. Importantly, Mr. Veteran did report having one male friend who he was having coffee with daily prior to coming to the hospital. Although the friend has tried to visit, Mr. Veteran was not available (due to a medical appointment) when the visit occurred, and he has not tried to contact the friend to follow up. When asked about this, Mr. Veteran said “why bother, he doesn’t want to come here anyway, I’m doing him a favor by not calling him.” Although the examiner asked permission to contact the friend (to gain collateral information), Mr. Veteran declined and said he did not want the man called. The veteran reported that his mood is variably depressed and he has begun again to think extensively about a woman in Vietnam with whom he was trying to develop a relationship. He reported having dreamed about her in the past couple of weeks, and one of the nurses working with him reminds him very much of that woman. He denied active SI/HI, but was tearful at times in recounting his feelings of emptiness and loss/trauma. He said, “If I just don’t wake up tomorrow, that would be ok with me.” He denied ongoing problems with depression earlier in life.

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Prior to entering the hospital, Mr. Veteran had been living in a small studio apartment and had done all his own cleaning, shopping, and other daily tasks with no trouble. His income includes his retirement and some Social Security. He has always looked after his own money, and denies any problems with this. Since coming into the hospital, he has stopped paying his rent and has received a notice of eviction. He feels plans to do nothing about this, saying, “What’s the use now?” Mr. Veteran enjoys playing guitar.

Substance Use Mr. Veteran indicated that he had used alcohol frequently while in the service, mostly in Vietnam and for about 4–5 years following that. At one point, he was drinking to the point of mild intoxication at least twice per week. Following that, he cut down on drinking substantially, having a beer or two each week for many years. However, in the last 10 years he has not been drinking as he says it upsets his stomach and digestion. He denied any legal problems, ongoing health issues, or other problems due to alcohol use. He said he used marijuana about 4 times in total, as a teenager and in his early 20s (“to see what all the hype was about”) but did not like the effect so never used it after that. He denied other illicit drug use. He smoked cigars for about 10 years beginning when he was in Vietnam, about 2 per day, but has not smoked in nearly 40 years.

Tests/Procedures Clinical Interview; Review of CPRS information; Shipley Institute of Living Scale-2 (SILS-2); Geriatric Depression Scale (Full 30-item version); Brief Symptom Inventory (BSI); Trauma Symptom Inventory-2 (TSI-2); and, Repeatable Battery for the Assessment of Neuropsychological Status (RBANS).

Findings Behavioral Observations Mr. Veteran was seen in an office in the CLC, across 4 sessions. These occurred on date, date, and date. He was generally oriented for person, place, overall time, and situation. During all sessions, he was dressed in hospital pajamas and robe. His overall hygiene appeared adequate. He was brought to the office in a wheelchair, and he remained in the chair during testing. When asked about his use of the chair, he reported not “feeling like my legs are all there.” When asked further, he explained that he felt physically weak, though through PT he has gained some ability to walk. His overall range of affect appeared blunted, though he also appeared mildly anxious. When asked about his mood, he reported “tired I guess, very tired, I just don’t feel like doing anything, yeah I’d say depressed I guess.” Eye contact was quite variable. Speech was perhaps somewhat slow, but was otherwise fluent. His self-appraisal of his actual test performance was low, and he tended to hesitate when not sure of an answer, needing additional encouragement to respond. There was no obvious evidence of overt disorder of thought process, and he denied hallucinations.

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Symptom Validity While Mr. Veteran sometimes needed additional encouragement to begin a task, his overall level of cooperation and effort appeared at least adequate to provide valid assessment results. Additionally, he achieved an RBANS effort index of zero, consistent with adequate effort, and he produced a valid TSI-2 profile, with possible underreporting of problems. Thus, the overall results of this evaluation are seen as a valid reflection of his functioning in the areas assessed.

Summary of Selected Test Results SILS-2: Vocabulary 59th percentile Abstraction 48th percentile IQ Estimate 52nd percentile Abstraction Quotient 35th percentile GDS:  raw score 16 (Depressed Range) BSI:  Elevations on Depression, Interpersonal Sensitivity, and Somatization TSI-2:  Elevations on Depression, and Intrusive Experience, mild elevations on Anxious Arousal, Suicidal Ideation, and Rejection Sensitivity CAGE Questionnaire: raw score 1 RBANS: List Learning Total 46th percentile Story Memory Total 49th percentile Figure Copy Total 45th percentile Line Orientation Total 73rd percentile Picture Naming Total 60th percentile Semantic Fluency Total 43rd percentile Digit Span Total 48th percentile Coding Total 40th percentile List Recall Total 49th percentile List Recog. Total 52nd percentile Story Recall Total 56th percentile Figure Recall Total 47th percentile Total Scale 49th percentile

Summary and Conclusions The results are seen as consistent with the presence of significant depressive symptoms with some ongoing anxiety, which might best be conceptualized as resulting from Mr. Veteran’s change to an inpatient status, with some loss of reinforcers and the loss of privacy in this individual who has always had some difficulty integrating himself into social situations. Furthermore, he expressed discomfort about being around others in a close living situation, which is likely adding to his level of stress at the current time. He has become quite concerned about his somatic functioning, and during the interview he reported being worried about whether his hip would ever fully recover. While a diagnosis of depression per se might be possible, given the time frame and his denial

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of depression prior to entering the hospital, the presence of Adjustment Disorder with Mixed Anxiety and Depressed Mood seems most appropriate at this time. While Mr. Veteran reported a criterion A stressor (i.e., the explosion in the bar in Vietnam) and his scores, as well as information from the interview, suggest the presence of some features of PTSD, the overall results do not suggest a diagnosis of PTSD. However, the symptoms he is experiencing are distressing to him (e.g., he is experiencing intrusive thoughts about the death of the woman in the bar), and intervention as suggested below may be of some help. His transition to inpatient status, his ongoing awareness of the physical difficulties of those around him, and concerns about his own physical health are likely to have contributed to the emergence of a range of PTSD symptoms (which is not unusual following admission to LTC). In this regard, it is likely that his early experience of abuse has led him to be even more susceptible to the influence of later trauma. Results of cognitive and intellectual testing show overall average intelligence, with personal strengths in the areas of judgment of line orientation (which gives information about an individual’s ability to process nonverbal information when no constructional component is required), vocabulary, picture naming, and list recognition. His performance was average in the areas of new learning and delayed recall of both verbal and nonverbal information. His score was average on a test of constructions involving an untimed drawing. His score was also average on a test of speeded word generation. His score was average on a verbal test of passive attention. His lowest score (revealing a relative weakness but still average performance compared to age-related peers) was on a coding task. This latter subtest is speeded and requires that some energy be brought to bear to do well. The overall pattern of scores seems to be consistent with the presence of some degree of depression, but is not indicative of dementia. Furthermore, his cognitive and intellectual performance would not preclude discharge to a lower level of care when appropriate, including to independent living if his physical problems do not make this impossible. His reluctance to follow dietary restrictions does not seem attributable to memory problems, but seems more related to his general discomfort in the CLC and to some degree of nihilism as expressed in his statements reflecting a belief that he will never get better, that he will never leave the CLC, and so forth.

Diagnostic Impressions Adjustment Disorder with Mixed Anxiety and Depressed Mood PTSD Symptoms Noted Avoidant Personality Traits

Recommendations This is a complex situation for an individual who does not feel comfortable with much interpersonal contact and may take considerable time to become accustomed to the CLC, and who has not been able to find ways to occupy himself while here. However, I offer the following: 1. He does not appear particularly interested in group activities, though he might come to some events if they involve limited social interaction (e.g., music

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listening groups, movies). As he becomes more accustomed to others here, he may gradually be drawn into more group activities, though this should be at his own pace. He should be invited but not pressed. 2. He might benefit from an evaluation for the use of medication to address his mood, though he denied being particularly interested in such medications during this evaluation. 3. If possible, he should be provided diabetic candy and encouraged to use it to prevent himself from going off his recommended diet. He expressed some willingness to try this. 4. If possible, he might find it helpful to have access to a guitar. The use of a guitar has always brightened his mood. He is not sure if his guitar is still at this apartment, but as he is being asked to leave there it will be necessary to address his belongings. If someone is available to accompany him to his apartment to retrieve some belongings, I believe he would be very appreciative. 5. I would recommend that a volunteer be sought to take him outside in his wheelchair. He has always enjoyed walking, and getting outside might help to brighten his mood. However, he should not be expected to engage the volunteer in much discussion. 6. Although he does not appear to fit the criteria for a diagnosis of PTSD, his symptoms might well respond to some psychological intervention. I suggest that a clinician who provides PTSD treatment be asked about this and possibly to meet with him to determine his level of interest, and I will take the liberty of getting in contact with them should the team so desire. Furthermore, given the specifics of his thoughts around the death of the woman (i.e., his feeling of abandonment by God), a further visit from chaplaincy services should be arranged. He expressed a willingness to meet with them, at least on a time-limited basis. 7. In coordination with the team’s efforts, I will plan to visit him regularly to check on his mood and to consult with the team. At present, a diagnosis of adjustment disorder seems most appropriate. However, if his mood does not improve over time, particularly even after some of the above interventions are tried, a change in diagnosis to depression may be warranted. 8. In connection with my visits, I will provide some motivational interviewing in an attempt to enhance his level of effort in rehabilitation. Engaging more fully in rehabilitation may help to lift his mood. Furthermore, if the other efforts described above have some impact on his mood, the team is likely to see his prognosis for discharge to a lower level of care improve. In addition, with his permission and in collaboration with PT, I will plan to attend several appointments with him to further evaluate for level of effort. Thank you for the opportunity to assist in evaluation and intervention with this interesting and complex veteran. Please let me know if I can be of further assistance and, as stated above, I will begin to monitor and treat him with you.

4

Psychological Assessment of Veterans in Primary Care–Mental Health Integration Contexts L I S A K . K EA R N E Y, L AU R A O. W R AY, K AT H E R I N E M . D O L L A R , PAU L R . K I N G , A N D C H R I ST I NA L . VA I R

PRIMARY CARE–MENTAL HEALTH INTEGRATION Primary care (PC) has become the nexus of health care, with primary care providers (PCPs) serving as the de facto gatekeepers of all health care services, including mental health care (Beacham, Herbst, Streitwieser, Scheu, & Sieber, 2012). Mental health conditions are highly prevalent in PC, yet the majority of mental health conditions go undetected and untreated in the general PC setting (Kessler, 2009). As the largest provider of healthcare services in the United States, the Veterans Health Administration (VHA) has made substantial efforts to address this gap for veterans through the implementation of the patient-centered medical home. This approach centers on engaging patients as partners in their own care, increasing access to care and communication with patients, and providing patient-centered and coordinated team-based care (VHA, 2011). In 2010, VHA undertook a large-scale reorganization designed to fully implement medical home principles, with staff being organized into Patient Aligned Care Teams (PACTs). Mental health providers are key members of these expanded teams, decreasing stigma by providing mental health services within the PC setting. Primary care–mental health integration (PC-MHI) delivery strategies have been developed within (Oslin et al., 2006; Pomerantz et al., 2010; Rubenstein et al., 2010)  and outside the VHA system (Engel et  al., 2008; Hunter  & Goodie, 2010). As can be seen in Table  4.1, psychological assessment within these models takes a population-based approach that includes attention to screening, triage, and brief treatment, and differs significantly from more traditional mental health assessment practices. Instruments should be brief, valid for the general population, focused on common conditions, and repeatable to allow for tracking of individual and population outcome assessment.

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Table 4.1.  Comparison of Integrated Care and Specialty Mental Health Care Assessment Integrated Care Mental Health Specialty Care Focus on health of the PC population Provides intensive treatments to Most patients are healthy with only referred patients with diagnosed mild to moderate symptoms disorders Behaviorally influenced problems Most patients have moderate to severe symptoms Service Brief appointments (15-30 minutes), Comprehensive evaluation/ Delivery limited number of encounters treatment Structure Open, same-day, access scheduling 50–90 min therapy sessions Pre-scheduled appointments Assessment Screening measures detect common Screening measures used only to Approach but underdiagnosed conditions ensure that likely cormorbidities Brief, repeatable measures, focused have not been overlooked on presenting problem, allows Extensive evaluation is the norm documentation of baseline severity for tracking individual and population outcomes Focus of Problem-focused Diagnosis-focus Assessment Solution Oriented Extensive, varies by diagnosis and and Reports specialty area Population Focus

The implementation of a population-based approach with a focus on prevention and early intervention is critical for the primary care setting (Linton, 2004). In order to provide early intervention, screening tools must be used to identify common disorders such as depression, substance use disorders, and anxiety. Within VHA, annual mental health screening is required, and has been standardized for depression, post-traumatic stress disorder (PTSD), and alcohol misuse (Tew, Klaus,  & Oslin, 2010). At least 95% of all veterans receive annual screening for alcohol misuse and depression, with semiannual screening for PTSD, resulting in one of the most comprehensive screening initiatives within the United States (Tew et al., 2010). In order to be feasible within primary care time constraints, brief assessments may involve paper-based instruments given to the patient to complete in a quiet waiting area, especially if a technician is available to quickly enter data and make results immediately available to the psychologist. In some locations, computer-based administration is available to complete screenings and brief assessments, utilizing computer kiosks or tablets.

Diversity Considerations in Primary Care An important consideration in selecting assessment instruments is their applicability for any given population by gender, race, ethnicity, reading level, language preference, and other relevant diversity factors (Suzuki, Ponterotto, & Miller, 2007). PC psychologists must ensure that any instruments utilized are normed for use in PC settings and are appropriate for use with each patient (Haley et al., 1998). Instrument

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selection must be completed in the context of population diversity. For example, African Americans and Latino/as have been found to be less likely to have their mental health disorders detected in PC settings (Borowsky et al., 2000). This finding is particularly concerning given that both these populations are also less likely to receive specialty mental health care (Hu, Kline, Huang, & Ziedonis, 2006). PSYCHOLOGICAL ASSESSMENT IN VHA PRIMARY CARE SETTINGS VHA has delineated specific policy requirements and programmatic expectations for mental and behavioral health service delivery within PC settings (VHA, 2008). VHA guidelines for PC-MHI programming vary based on facility size, with larger PC venues being required to provide both care management and co-located collaborative functions. Care management (CM) programs must be based on approved evidence-based models (VHA, 2008). Regardless of the specific model, VHA mental health care management must include these functions: (a) monitoring adherence to treatment, treatment outcomes, and medication side effects; (b)  decision support; (c) patient education and activation; and (d) assistance in referral to specialty mental health care programs (VHA, 2008). The policy also stipulates that: [t]‌he co-located, collaborative care (CCC) model involves one or more mental health professionals who are integral components of the PC team and who can provide assessment and psychosocial treatment as needed for a variety of mental health problems, which include depression and problem drinking. (VHA, 2008, p. 35)

Assessments by PACT Providers Population-based screenings assist primary care providers in increasing the likelihood of appropriate diagnosis of mental health conditions, as some reports indicate that 50%–70% of PCPs fail to identify a current depressive disorder in their patients (Martin, Williams, Haskard,  & DiMatteo, 2005). Effective screenings result in cost savings by improving overall health care outcomes, by identifying individuals with undiagnosed mental health concerns who may inadvertently overuse services, and by decreasing inappropriate referrals for unneeded treatments (Auxier, Farley, & Seifert, 2011; Derogatis & Lynn, 2000; Valenstein, Vijan, Zeber, Boehm, & Buttar, 2001). Within VHA, standardized screening instruments include the Patient Health Questionnaire-2 for depression (PHQ-2; Lowe, Kroenke, & Grafe, 2005), the Primary Care- PTSD screen for PTSD (PC-PTSD; Prins et al., 2004), and the Alcohol Use Disorder Identification Test Consumption Questions (AUDIT-C; Bradley et  al., 2007) for identification of alcohol misuse. These instruments are most often administered by a PACT nurse or technician and are reviewed by the PC provider, who discusses positive screens with the patient and develops an initial treatment plan, which may include immediate introduction to the integrated mental health provider for additional assessment and follow-up.

Psychological Assessment in VHA Care Management Care management is a package of protocol-based services that support PC mental health interventions. Care management includes patient education, activation,

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monitoring of medication adherence, and structured, measurement-based assessment of progress over time, with facilitation of changes in treatment when necessary. A care manager completes a baseline measure of the veteran’s symptoms (see Appendix 4.1 for a sample care management baseline report) and calls the patient on a predetermined, evidence-informed schedule (Oslin et al., 2006; Tew et al., 2010). The baseline report is reviewed by a supervising clinician (i.e., potentially the CCC provider), who conducts additional follow-up assessment, if warranted, and makes triage recommendations. The care manager administers a brief assessment at each follow-up call, allowing the team to track the patient’s improvement. If improvement is not made, the care manager consults with the PCP and supervising provider, who will then make adjustments or change medications as needed.

Psychological Assessment in VHA Co-Located Collaborative Care The role of CCC providers is to support the PC interdisciplinary team through consultation and direct patient care services. CCC providers complete follow-up to routine mental health screenings, provide triage and emergent care, and conduct brief interventions for common symptoms. Visits may be done individually by the co-located provider or in joint meetings with the veteran and other PACT providers. The veteran’s team of providers develops a common conceptualization of the veteran’s health and mental health problems into a coordinated treatment plan. Ideally, CCC providers use assessments to assist clinical decision-making to determine need for specialty mental health referral, to identify potential treatments, and to track effectiveness of brief interventions. Unlike the care management models, specific assessment tools are not predetermined for CCC providers in VHA. While measures are not predetermined, the instruments noted previously are appropriate for use by CCC providers and would be useful for those providers working in settings where CM is present. Use of the same measures would allow outcome tracking over time, eliminating any need to complete additional baseline assessments. A critical role for CCC providers is following up on the required screenings completed by PCPs and nurses in PC. The primary goal of this assessment is to quickly identify (in 20 minutes or less) the severity of mental health concerns and to begin collaboratively establishing a treatment plan with the veteran’s input. A full psychological assessment, which typically takes 2 hours or more, is untenable within the context of a PC environment as outlined previously (see Appendix 4.1 for a sample CCC report). TEST MEASURES AND PROCEDURE OPTIONS

Recommended Procedures, Tests, and Batteries Mental and behavioral health concerns are frequently the focus of primary care visits. A number of brief screening and assessment tools (e.g., standardized measures, clinical functional assessment, chart reviews, and patient diaries) are available to assist in identifying mental and behavioral health concerns, gauging symptom severity, making triage decisions (i.e., whether to manage in PC or refer), and evaluating response to treatment. As detailed in Table 4.2, it is critical to understand the pros

Table 4.2.  Test Measures and Procedure Options Options Brief Instruments or Screenings

Description in PC Assessment Brief instruments (2–19 items) to identify potential symptoms

Brief Functional Assessment

Assess Veteran’s functioning acrossdomains (work, sleep, relationships, health)

Projective Tests and Consider using in PC rarely Full Personality Assessments Structured SCID or SCID II Interviews Brief Cognitive Used to detect early signs of dementia Assessments and help providers distinguish from late life depression Chart Review Notes by Provider/Specialty Medications Past Diagnoses Lab work/Vitals Patient Diaries Track behaviors targeted for intervention Review behavioral antecedents and consequences, analyzingcommon patterns and tracking progress

Pros Ease of administration and scoring Conforms to primary care pace Can be used by all PACT members Veterans appreciate focus on primary concerns Problem and solution focused Provides continuity of care with what PCP offered in the clinic that day Fits pace of PC clinic May increase diagnosis accuracy

Increases diagnostic accuracy Guides questioning process Can be administered quickly Can help identify when more in-depth cognitive or neuropsychological testing needed Can review history of lab levels in area in which a patient is targeting interventions for improvement (e.g., CBT for increasing exercise for improved diabetes) Patient is an active participant Self-monitoring impacts monitored behavior

Cons False positives possible May be over-interpreted by those not familiar as yielding diagnosis Clinicians more familiar with traditional assessment may find this approach challenging Does not always result in full, multi-axis mental health diagnosis Projectives lack face validity Require lengthy administration and interpretation time Too lengthy for full administration in PC Use of partial instruments for screening may invalidate full batteries Prior knowledge of medical conditions is required May not be able to complete review prior to unscheduled appointments May be challenging to implement, but may serve as an opportunity to address barriers to change

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and cons of each form of assessment and how/when each can be appropriate for application within PC. Successful measurement-based care practice requires measures that are reliable and valid, repeatable, and sensitive to change over time. Repeatable assessments should be used at each patient visit. Table 4.3 provides details on a number of these measures, including estimates of sensitivity and specificity where available. Considerations for several of the most common conditions are found below. As depicted within each section, assessment in PC should include initial screening, follow-up assessment for positive screens via brief standardized measures, determination of the most appropriate care setting based on symptom severity, and routine tracking and monitoring of patient outcomes.

Depressive and Bipolar Disorders Depression Based on the DSM-IV criteria, major depressive disorder is present in 5%–13% of patients seen by PC physicians (Pignone et al., 2002). Approximately 7% of VA patients meet criteria for major depression, with depression accounting for 14.3% of total VA healthcare costs (Rubenstein, Chaney,  & Smith, 2004). Many patients with depression are initially detected in PC settings, with 13% to 20% of PC patients screening positive for depressive symptoms (Foster et al., 1999). Routine screening improves detection of depression by 10%–47% (Pignone et al., 2002). Current VA clinical practice guidelines require that all patients be screened for depression annually (VHA, 2009). Standardized, brief, and repeatable instruments appropriate for the PC setting, such as the 9-item Patient Health Questionnaire (PHQ-9; Kroenke, Spitzer,  & Williams, 2001), the Center for Epidemiologic Studies-Depression Scale (CES-D; Williams, Pignone, Ramirez,  & Perez Stellato, 2002), and Geriatric Depression Scale (GDS; Watson & Pignone, 2003), should also be used to aid in depression diagnosis, measure of symptom severity, and to assess treatment response. For example, an individual may screen positive on the PHQ-2 and then be assessed with the PHQ-9, the results of which will inform treatment choices based on symptom severity. The PHQ-9 should then be administered at each contact to track symptoms over time.

Bipolar Disorder Bipolar disorder is a common but under-recognized diagnosis in PC. An estimated 20%–30% of patients who present to PC with symptoms of depression and/or anxiety likely have bipolar disorder (Manning, 2010). The Mood Disorder Questionnaire (MDQ) consists of three main questions, has been validated for use in the PC setting, and can be administered by providers or self-administered by patients (Hirschfeld et al., 2000) to inform an initial differential diagnosis and determine whether referral to specialty mental health care may be warranted. The Mini-International Neuropsychiatric Interview (MINI; Sheehan et al., 1998) also contains a module specific to manic or hypomanic symptoms that can be easily administered within the PC setting. If the screening items are positive, additional assessment with included follow-up items is warranted and should be administered

Table 4.3.  Brief Measures That May Be Used in Primary Care Measure ADHD Adult ADHD Self-Report Scale (ASRS)∞ - 6-item Adult ADHD Self-Report Scale (ASRS)∞ - 18-item Wender Utah Rating Scale (WURS)© - 25-item Alcohol Misuse/Dependence Alcohol Timeline B,∞- 4-item Alcohol Use Disorders Identification Test (AUDIT)†, ∞: 10-item

Source

Time (min.)

Cut Score

Sensitivity/ Specificity

Hines et al. (2012); Kessler et al. (2005) Kessler et al. (2005)

1

4

5

4

.69–1.0/.71–.99 More sensitive than 18-item version, though infrequently used in VA PC. .56/.98 Frequency scores may assist in gauging severity, but do not improve diagnostic value. .72–.86/.58–.99 Assesses common ADHD symptoms, although some research suggests high false positive rates.

McCann et al. (2000); ~5 Ward et al. (1993)

46

Sobell et al. (1988)

-

2

Considerations for Use in Primary Care (PC)

-

Highly reliable estimate of past week drinking, though limited to very recent drinking behaviors. .87–1.0/.66–.98 Routinely administered in VA. Cut point of 8 too high for use in Veteran samples.

Saunders et al., (1993) 2–4

8

VA/DOD (2009); 2–4 Bradley et al. (2007) VA/DOD (2009); 2–4 Bradley et al. (2007) Bradley et al. (2003) 2–4

5

.81/.90

Identifies risky drinking practices.

4

.91/.80

Identifies diagnosable alcohol use disorder.

2

.87/.71

Alcohol Use Disorder VA/DOD (2009);