Professor David Gilden

“Just the thought of sitting through a meeting or going to the movies makes me feel anxious,” says Susan, who asked to be identified by her first name only, in fear of being stigmatized by Attention Deficit Hyperactivity Disorder (ADHD). “My mind is bouncing around like a ping-pong ball and I can’t focus on one thing for longer than a few minutes.”

Susan is among the estimated 5 percent of American adults who, according to the National Institute of Mental Health, are living with ADHD, a neurobiological condition marked by impulsive behavior and a lack of focus.

University of Texas at Austin psychologist David Gilden’s research findings suggest the underlying problem doctors have diagnosing ADHD may be in recognizing that it is not an issue of attention, but rather a problem of timing. According to his research, people with ADHD have a much quicker sense of the here and now, such as the moment it takes to thread together two sentences in a classroom lecture. This timing glitch often causes them to fall out of sync with the rest of the world.

Once diagnosed, the symptoms of ADHD are often managed with stimulant medication, but according to Gilden, to effectively treat the disorder clinicians need to have a clear understanding of the underlying deficit.

“The first thing in any treatment is understanding what it is that’s being treated,” Gilden says. “At this time, that’s missing. People have been focusing on ADHD as if it’s an attention disorder, but I don’t think that’s what it is.”

Using drums, Legos, puzzles and Play-Doh, Gilden and his team of researchers are searching for the root cause of ADHD. By allowing their study participants to tinker with the toys in an unconstrained environment, the researchers are able to track timing differences in their natural behaviors.

“ADHD is not about inattention,” Gilden says. “It’s a disorder in the way people thread moment-to-moment experiences together. Children with ADHD are often disruptive because their world is moving at a much faster pace and there’s always going to be a mismatch between their world and ours.”

As part of his research, Gilden measured how people with and without the disorder tap along to the beat of a metronome. The respondents then continue tapping at the same pace for three minutes after the metronome stops. Although both groups were able to tap to the beat at 60 beats per minute, the participants with ADHD lost the rhythm when the tempo slowed down to 40 beats per minute.

“The slower the tempo, the more likely people with ADHD will be less internally consistent with themselves,” Gilden says. “It’s not that they’re inattentive, it’s just that their world is moving along at a slightly faster clip.”

To measure the timing disruptions, Gilden and his team videotaped the hand movements of more than 60 undergraduate students as they worked on various projects like piecing together a puzzle, building Lego structures or molding Play-Doh.

After conducting a frame-by-frame analysis of the action sequences of each hand movement (such as touching a puzzle piece and fitting two pieces together) the researchers found significant differences in timing between ADHD and non-ADHD participants.

Although both groups used similar action sequences and constructed their Lego and Play-Doh projects in the same order, the participants with ADHD took about one-third of a second longer carrying out a task like fitting two Lego pieces together.

“One-third of a second seems like a short amount of time, but in psychophysics, this is a huge timing difference because it only takes the average person one-tenth of a second to initiate an action,” Gilden says. “This is a very puzzling discovery because although their minds are moving at a faster rate, they’re actions are more spacious.”

Sifting Through the Noise
While all the participants moved freely during the study, Gilden, who holds a doctorate in astronomy, found a hidden structure in the patterns of their actions. He found each moment-to-moment fluctuation in hand movements resembles 1/f noise (pronounced one over F), which is not an audible noise, but a mysterious wave-like pattern that appears in natural and unnatural surroundings. Investigated by scientists for more than a century, the noise has yet to be explained.

Gilden is the first to show that 1/f exists in human consciousness. In a 1995 study published in Science, he found that all humans produce the noise. However, his recent studies have shown that the noise is much harder to detect in people with ADHD, as their movements are more erratic.

From fluctuating weather patterns, to the beating of a heart, to pitch and loudness in music and speech, our world is full of 1/f noise. To illustrate this highly complex concept, Gilden plays a piano rendition of Summer Samba. In between the fluctuating tempos and repetitive melodies, he explains how the patterns in music achieve 1/f noise.

“When you listen to this song, you’ll find that it follows a formula of repetition and surprise folded into a pattern of organization,” Gilden says. “Music is the blend between the ordered states and disordered states, and that’s exactly what 1/f achieves.”

To measure cognitive timing differences between people with and without ADHD, Gilden and his team of researchers analyze their hand movements as they build Lego structures in an unconstrained environment. (click to enlarge)

Using Gilden’s research, James Cutting, professor of psychology at Cornell University, studies how editing techniques in filmmaking follow the pattern of human attention. In a recent study, he found the basic shot structure and scene clusters in movies have evolved over the years to resemble the pattern of 1/f noise.

By timing the scenes just right, moviemakers can capture the viewers’ attention without overly taxing their attention span, Cutting says. If the audience hears something the brain doesn’t recognize as the correct sequence – such as quick zooms and pans – they’re unable to make the connections and their minds wander.

Gilden’s research shows compelling evidence that people think, focus and refocus their minds, all at the speed of 1/f, Cutting says.

“When you’re working on a task, sometimes you’re good at it, sometimes you drag and sometimes you zone out,” Cutting says. “We experience these periods of fluctuation throughout our daily lives. And each of these fluctuations creates waves that essentially form a 1/f pattern.”

By applying this theory to ADHD research, Cutting says Gilden is on the right track to understanding the underlying deficit.

Understanding Attention
More than 5.4 million children in the United States have been diagnosed with ADHD according to the Centers for Disease Control. And as that number continues to grow, Gilden says researchers and clinicians need to find out if the disorder has anything to do with attention.

“What is attention? It’s such an abstract concept,” Gilden says. “Attention involves focusing and letting go at the same time, but other than that – I’m not sure what it is.”

This has made treating the disorder particularly difficult. After being diagnosed with ADHD, people are often prescribed psychotropic drugs that come with an array of side effects like mood swings and loss of appetite. The problem with this method, Gilden says, is that clinicians are treating a condition that they do not fully understand.

Without a clear understanding of attention, psychologists have made very little progress in identifying cognitive deficits in ADHD, Gilden says.

“You can’t find a cure until you understand the underlying problem,” he says. “If a doctor suspects you have the flu, he can prescribe a drug specifically targeted for that virus. But when psychologists diagnose people with ADHD, they need to understand what the deficit is before prescribing a full spectrum of treatment that has nothing to do with the condition.”

To seek out the underlying deficit, he examines the disorder from an entirely new perspective by applying an anthropological approach to his research.

“The problem with most ADHD research involving time-pressured experimental trials is that people with the disorder tend to be more erratic,” Gilden says. “We’re interested in the natural flow of behavior. Instead of giving them time-pressured tasks, we allow them to generate their own thoughts and actions.”

Diagnosing a Growing Epidemic
So what is behind the rise in ADHD diagnoses? That is the question plaguing millions of parents every year. Is it a biological illness, environmental toxins or a mere alibi for rambunctious children?

Despite decades of research, the underlying problem still remains unclear. However, recent mounting evidence in brain studies has shown that the deficit is caused by a stunted dopamine system, the brain’s reward pathway that associates stimuli with pleasurable expectations.

Using Play-Doh, the researchers examine how people with ADHD move to the beat of a faster cognitive tempo. Over time, Gilden aims to create diagnostic tools using drumming, Play-Doh and other methods to replace current diagnostic tests, which he believes are ineffective.

Since dopamine is also involved in memory, learning and motivation, the chemical helps people pay attention to the information they need to survive. However, those with ADHD might not be recognizing salient information due to an impaired dopamine system, Gilden says.

In a current study, funded by the National Science Foundation, Gilden and his team are examining how the effects of dopamine dysfunction play into the production of 1/f noise. They found that when participants with ADHD are thrust into a stress-induced environment involving time-pressured tasks, their behavior resembles the kind of noise that a radio makes when not tuned to a station – what scientists call a white noise.

This finding suggests that situations like structured classroom activities, final exams and prolonged meetings are not conducive to people with ADHD. Gilden says researchers, parents and teachers need to take a step back and look for new ways to help people with the disorder adjust to the world around them.

“Our research is motivated by the idea that there is something deeply wrong with the accepted view of ADHD and how people with ADHD are understood,” Gilden says.

The harmful effects of ADHD sometimes persist into adulthood, and many adults who have it do not know it. As a result, they fail to seek treatment and continue to struggle at work or in school and in their personal relationships.

Over time Gilden hopes to create a diagnostic tool using drumming and other methods to replace other diagnostic tests, which he says are ineffective.

Professor David Gilden and his graduate research assistants, Maryam Ezell (left) and Laura Marusich, examine frame-by-frame hand movements in videos to measure cognitive timing differences between people with and without Attention Deficit Hyperactivity Disorder. (click to enlarge)

Caryn Carlson, professor of psychology and assistant chair of the Psychology Department at the university, says findings from Gilden’s research could help teachers capture their students’ attention through strategically timed lectures and classroom activities.

“There is typically a mismatch between the demands of the classroom environment and the attention style of children with ADHD,” Carlson says. “This may be characterized by an inability to focus during extended desk work sessions, missing task instructions due to distractibility and making careless errors.”

Carlson cites other research findings that show the consequences of untreated ADHD, even after children are finished with school, can have a profound impact on their lives.

“When children fail to master critical early academic skills, the effects on school performance can become cumulative and result in failure, frustration and demoralization,” Carlson says.

Looking back, Susan says she wishes her teachers developed classroom activities that were more conducive to students like herself who were chronically bored and restless.

“Back then, I was all over the place,” Susan says. “I couldn’t handle the structure and the teachers didn’t know what to do with me. For the longest time, I thought something was very wrong with me, which is why I have such poor self-esteem. If I was diagnosed early on – who knows – I may have achieved my goal of becoming a history professor.”

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http://austin.ynn.com/content/279818/health-works–ut-researchers-study-adhd-diagnosis

Original article by Jessica Sinn at University of Texas.

“Depression and PTSD exert a significant, independent, and persistent effect on general health, work status, somatic symptoms, adjustment to illness, and function after injury,” the authors wrote, also emphasizing that even minor injuries can lead to traumatic stress responses. The findings allow healthcare providers to identify patients at highest risk for developing these disorders and to target appropriate resources to this vulnerable group.

This screening tool – reportedly one of the first of its kind for adults in the U.S. – could have a great impact on the judicious allocation of costly mental health resources.

Using an eight-question survey, all injured patients can be rapidly assessed for risk in the hospital. Healthcare providers can then provide patients classed as high-risk for developing depression or PTSD with information about symptoms to look for and advise them to contact their primary care provider should symptoms surface. This intervention can facilitate early diagnosis of these disabling disorders.

The study reported nearly 100 percent accuracy in negative results. Only five percent of injured patients who tested negative for risk of depression on the screening survey developed depression and no patients who tested negative for PTSD risk developed PTSD. At the same time, not all patients who screen positive will develop these disorders. The researchers do not suggest that all patients who screen positive receive mental health services, but rather that this finding prompt systematic provision of information and additional follow-up.

The authors caution that while the findings of this initial study are most promising, they need to be replicated in an independent sample.

The other authors involved in the study were: Josef Ruzek, PhD; Theimann Ackerson, MSSW; Douglas J. Wiebe, PhD; Flaura Winston, MD, PhD; Nancy Kassam-Adams, PhD.

Material adapted from University of Pennsylvania School of Nursing .

Researcher Eivind Ystrom

Results will be published in the September 2011 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

“People are inaccurate when interviewed about their history of psychiatric symptoms,” observed Eivind Ystrom, a researcher at the Norwegian Institute of Public Health and corresponding author for the study. “The most obvious reason for this is that people just don’t recall when prompted. Thus, by interviewing people several times about the same disorder it is possible to estimate to what extent people are inaccurate.”

“This study is unique in that Ystrom and his colleagues report that certain variables, including a specific AD criterion, robustly predict the reliability of the diagnosis,” said Alexis Edwards, a postdoctoral fellow at the Virginia Institute for Psychiatric and Behavioral Genetics, Virginia Commonwealth University. “Obviously, all of the symptoms are, at some level, predictive of the disorder; but that some are more useful than others at identifying a reliable diagnosis is interesting.”

The researchers examined a population-based sample of male twins in Virginia (n = 4,203) who had been assessed for LTH-AD on two different occasions one year apart (i.e., each pair of twins were assessed twice at about the same ages, one year apart). Logistic regression was used to identify clinical features that might predict a reliable diagnosis. Genetic and environmental influences were also examined.

“The first key finding was that men who are diagnosed with LTH-AD using a clinical interview tend to have many symptoms of AD, they have at some point in their life sought treatment for their AD, their period of life with AD lasted a long time, or they spent much time on obtaining alcohol or recovering from alcohol use,” said Ystrom. “The second key finding was that, after taking into account that people are inaccurate when reporting psychiatric symptoms, the heritability of LTH-AD was estimated to be 71 percent. Or, put another way, 71 percent of the causes as to why some people in the general population become AD, while others do not, were genetic.”

“This higher heritability of the LTH-AD phenotype, a bit higher than we might have expected, confirms the importance of genetic influences,” added Edwards. “Furthermore, while the reliability of the diagnosis itself is moderate, results show that we can potentially increase our confidence in the diagnosis by taking into account a few specific variables.”

“Since the study identifies which characteristics are associated with a reliable diagnosis,” said Ystrom, “these characteristics can be used to enhance the reliability of single measures of LTH-AD. In addition, although psychometric theory states that the heritability should go up as the diagnostic reliability goes up, this study describes the phenomenon empirically. Finally, by estimating the heritability of LTH-AD to 71 percent, the study moves AD into a class of disorders that are highly dependent on genes, such as schizophrenia or bipolar disorder.”

Both Ystrom and Edwards see practical implications from these findings for various audiences.

“Researchers often want to know what characterizes people with a disorder,” said Ystrom. “If the diagnoses of the cases in their sample are inaccurate, they will be less able to correctly describe the characteristics of the people with the disorder.”

“Clearly clinicians would be interested in reliable diagnoses because of their goal of providing appropriate treatment for patients,” said Edwards. “Clinicians need to be confident that a patient truly has a disorder before embarking on a treatment program, whether that involves counseling, pharmaceutical treatment, or something else.”

“However, the finding that LTH-AD is a disorder which is to a great extent dependent on genes, is also important to the public,” said Ystrom. “Some people might view AD purely as a matter of will. Since most people in the western world use alcohol regularly, but only a few become dependent on it, it is significant to know that much of the reason why this happens to people is because of individual genetic vulnerability. Genetic vulnerability is not a demerit.” Edwards concurs. “Most people know someone who has struggled with alcohol problems, and this report underscores the fact that the disorder is very complicated, and is a function of both biology and the environment. While some of the nuances of the report might be too technical to be relevant to someone not involved in this research, the general findings are still of broad interest simply because AD affects so many people, directly or indirectly.”

Material adapted from Alcoholism: Clinical & Experimental Research.

Reference
Eivind Ystrom, Ted Reichborn-Kjennerud, Steven H. Aggen, Kenneth S. Kendler. Alcohol Dependence in Men: Reliability and Heritability. Alcoholism: Clinical and Experimental Research, 2011; DOI: 10.1111/j.1530-0277.2011.01518.x

The issue, the researchers explain, is that the official definition of when a patient’s symptoms are in remission does not always match up with what doctors see in a real-world practice, especially for patients with mild to moderate symptoms. The study will be published in the upcoming issue of General Hospital Psychiatry.

“Rather than simply going down a list and checking off a patient’s lack of individual symptoms, we believe there are also positive signs that are important – a patient’s feeling that they are returning to ‘normal,’ their sense of well-being, their satisfaction with life, and their ability to cope with life’s ups and downs,” says lead author Donald E. Nease Jr., M.D., who was an associate professor of family medicine at the U-M Medical School and member of the U-M Depression Center at the time of the research.

Nease and his colleagues developed a series of five questions – such as, “Over the last two weeks, did you feel in control of your emotions?” – that they hope will help doctors better understand a patient’s inner landscape.

The remission criteria spelled out in the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) does not necessarily correspond to a patient’s own sense of recovery, Nease explains.

For example, a patient could meet all the criteria for full remission, but still not feel that he had recovered. REMIT is intended to add the patient’s subjective sense of recovery into the equation.

Rather than a replacement for current tools and measurements, REMIT is intended to compliment them, say Nease, who is currently an adjunct professor at U-M.

The researchers used the REMIT tool alongside the current “gold standard” for monitoring people with depression, the Patient Health Questionnaire (PHQ), Nease explains. The data showed that by adding in the REMIT questions, about one-third of patients with mild depression were not in remission, as their PHQ score would indicate. Additionally, about one-third of moderately depressed patients were doing better than their PHQ scores alone would denote.

“Using just the PHQ score across our study population, we saw about 60 percent accuracy in reflecting a patient’s remission compared to the patient’s sense of his or her own recovery,” Nease says. “If you add in the REMIT questions, we get above 70 percent. This can give doctors new insights when making treatment choices, such as changing a patient’s medication or dosage.”

The current research looked at a single snapshot in time for nearly 1,000 patients. The next step will be to track patients’ scores over time. Unlike other tools that require a company’s permission to use, the REMIT tool is available to any doctor who wants to use it, Nease says.

Additional Authors include: James E. Aikens, Ph.D., Michael S. Klinkman, M.S., M.D., Ananda Sen, Ph.D., all of U-M. And Kurt Kroenke, M.D., of Roudebush VA Medical Center and Indiana University.

Material adapted from University of Michigan Health System.

Download
Download the Remission Evaluation and Mood Inventory Tool (REMIT).

Note: For scoring, please consult the original journal article (citation with link below).

Reference / Astract
Donald E. Nease Jr. M.D., James E. Aikens Ph.D., Michael S. Klinkman M.D., M.S., Kurt Kroenke M.D., and Ananda Sen Ph.D.”Toward a more comprehensive assessment of depression remission: the Remission Evaluation and Mood Inventory Tool (REMIT),” General Hospital Psychiatry, DOI: 10.1016/j.genhosppsych.2011.03.002.

The findings emerge from the first ever general population survey of autism in adulthood. They are based on a two phase epidemiological survey in England (7,461 screening interviews; 618 diagnostic) carried out in 2007. The findings are now published fully in the world’s leading peer refereed mental health scientific journal the Archives of General Psychiatry. This means that the survey carried out from Leicester is now internationally endorsed officially.

Dr. Brugha, who is also a consultant psychiatrist working in the NHS with the Leicestershire Partnership NHS Trust, said none of the cases with autism found in the community survey throughout England knew that they were autistic or had received an official diagnosis of autism or asperger syndrome.

Dr. Brugha said the new scientific article confirms the already published report from the survey (2009) that 9.8 per thousand adults in England meet official diagnostic criteria for autism spectrum disorder. There was no evidence of an ‘autism epidemic’ of marked increase in people with the condition.

He said: “Overall our findings suggest that prevalence is neither rising nor falling significantly over time. This favors the interpretation that methods of ascertainment (case finding) have changed in more recent surveys of children compared to the earliest surveys in which the rates reported were considerably lower”.

In a comment on the possible causes of autism the researchers suggest that “the [non-genetic or environmental] causes of autism appear to be temporally constant, and that recent apparent rises in rates of diagnosis must therefore reflect better case finding, rather than some new environmental toxin. However, we would urge caution and the need for independent replication of this first set of adult community survey findings”.

Professor Brugha also drew attention to the newly reported finding that none of their cases of autism were already known to have the condition: “It is very concerning that none of the cases we confirmed using rigorous diagnostic assessment methods in the community knew that they had the condition or had an official diagnosis. As in all community surveys it is of course likely that most of the cases we found were relatively mild and few were severe. We know that severe autism particularly when accompanied by learning disability is much more likely to be recognized. We are beginning to provide training to psychiatrists in the diagnosis of autism spectrum conditions in adulthood through the Royal College of Psychiatrists Education and Training Centre, London.”

The initial findings of the survey, which appeared first in 2009, attracted considerable media attention. The survey was carried out jointly with the National Centre for Social Research and a team of methodological experts from collaborating Universities (University of Cambridge, UCL, and King’s College, London). Further work extending the survey to adults in communal establishments and adults with Learning Disability has since been commissioned by the NHS Information for the Department of Health and is being carried out in collaboration with researchers at the Universities of Cambridge and Glasgow. The findings are expected to become available later in 2011.

The study was supported by the National Health Service Information Centre for Health and Social Care and Department of Health; autism follow-up was supported by the National Institute for Health Research and Department of Health Policy Research Programme.

Material adapted from University of Leicester.

Download
Interview Guide for the Diagnostic Assessment of Adults with Autism Spectrum Disorder (ASD).

The study titledAssociation of FKBP5, COMT and CHRNA5 Polymorphisms among Outpatients at Risk for Posttraumatic Stress Disorder, finds that individuals with a certain set of “at risk” genes were at seven times higher risk for PTSD than those without the genes.

“We found that individuals with these ‘at risk’ genes were more likely to develop PTSD, especially when associated with a higher exposure to traumatic events or greater exposure to childhood adversity,” said Dr. Boscarino. “They say what doesn’t kill you makes only you stronger, but what we’ve found is that the opposite may actually be the case if you have the PTSD risk genes.”

Boscarino adds that genetic screening individuals for these genetic factors in the future may lead to better post-trauma treatments and genetic counseling related to career options in the military or in the civil services, such as police work or firefighting.

In a related study, Development and Validation of a New PTSD Prediction Tool for Use in Clinical Practice, Dr. Boscarino and his team developed a PTSD prediction tool that can be used in clinical practice after traumatic event exposures. After collecting information from more than 2,300 adults following the September 11 terrorist attack on the World Trade Center, Boscarino’s team examined various clinical factors including stressor exposures, psychosocial resources, functional status, depression, suicidal thoughts, PTSD symptoms, and demographics to evaluate different PTSD prediction models.

The team then developed a simple 10-item prediction tool that included core PTSD symptoms, depression symptoms, personal physician status, sleep disturbance, and trauma history. Findings show the tool is highly successful in predicting PTSD following traumatic exposures in different clinical populations, including a sample of chronic pain outpatients and a sample of Level-I trauma patients discharged from Geisinger Clinic.

“Until now there’s been no easy-to-use tool to help clinicians rapidly identify PTSD in patients in routine practice or after a traumatic event,” said Boscarino. “We now have a 10-step process that can accurately and quickly identify PTSD cases from non-cases and facilitate the most appropriate therapy.”

Material adapted from Geisinger Health System.

Results will be published in the June 2011 issue of Alcoholism: Clinical & Experimental Research and are currently available at Early View.

“Children with FASD and ADHD can appear very similar,” explained Sarah N. Mattson, a professor in the department of psychology at San Diego State University and corresponding author for the study. “Both alcohol-exposed children and those with ADHD demonstrate behavioral difficulties, such as hyperactivity and impulsivity, and children with FASD often meet diagnostic criteria for ADHD. Studies that compare these groups can aid in accurate identification and appropriate diagnoses, which are important as they have implications for the kinds of interventions and resources provided to these children and their families.”

“The broad range of neurodevelopmental, cognitive, and behavioral abnormalities that occur in FASD most likely result from a combination of prenatal alcohol exposure and other factors, such as other drug exposures, disrupted home environment, abuse, and co-morbid conditions,” added Jeffrey R. Wozniak, assistant professor of psychiatry at the University of Minnesota. “This heterogeneity or wide range of potential problems among this population remains a significant challenge to researchers attempting to identify a ‘profile’ of abnormalities that are associated with PAE.”

Mattson and her colleagues used the California Verbal Learning Test – Children’s Version (CVLT-C) to examine three groups (n = 22 per group) of children, ages 7 to 14: those with heavy PAE and ADHD (10 boys, 12 girls); those not exposed to alcohol and with ADHD (14 boys, 8 girls); and those not exposed to alcohol and without ADHD (12 boys, 10 girls). The groups were matched on age, sex, race, ethnicity, right or left-handedness, and socioeconomic status. The test required the children to learn and remember a list of words.

“The children with alcohol exposure had problems with learning information initially, but they were able to remember what they did learn later on,” said Mattson. “The children with ADHD, however, were better at recalling information immediately after it had been presented, but had difficulty retaining this information over time.”

“This pattern of results suggests that FASD may be associated with a specific deficit in the initial encoding of verbal information while, in contrast, ADHD may be associated with a deficit in retrieval,” said Wozniak. “The authors speculate that the encoding problems seen in FASD may be related to underlying difficulties in executive functioning – those processes by which a child organizes and directs his/her own learning.”

Mattson explained that “inefficient encoding of verbal material” means that when children are presented with verbal information, they have difficulty learning that information. “If children have encoding deficits, it may be experienced as a memory problem as they will recall less than their peers,” she said. “They may also find it difficult to remember and follow instructions given to them by teachers or parents and have difficulty learning material presented in the classroom.”

A “deficit in retrieval of learned material,” on the other hand, is related to memory but is different from “forgetting,” said Mattson.

“If a child has a difficulty retrieving learned material, the problem is related to accessing material that is stored in the brain,” Mattson explained. “These children won’t be able to independently generate the material, but if you presented them with some choices they could recognize the correct answer. ‘Forgetting’ refers to learned information that is no longer available for recall.”

“Children with FASD might need additional repetition of the information as well as guidance about how to organize the information as they are learning it,” added Wozniak. “In contrast, children with ADHD might benefit most from assistance in developing strategies for retrieving information from memory, such as self-cueing.”

“This research has important implications for clinicians and educators,” noted Mattson. “Understanding the profiles of learning and memory impairments in these populations of children can allow for appropriate intervention and remediation strategies to be implemented.”

Wozniak agreed. “Both educators and clinicians will benefit from knowing that children with FASD are, in fact, struggling at the level of encoding information but that their retrieval mechanisms are less affected. Individuals with FASD might benefit most from additional efforts to improve their initial encoding, such as developing strategies for active learning and techniques for ‘deepening’ their initial processing in order to improve encoding of the information into memory.”

Material adapted from Alcoholism: Clinical & Experimental Research.

The study looked at Medicaid well-child visits that included behavioral screens from 2008-2009. They found that, under the new mandate, the number of screens completed in the state increased from 80,000 a year to 300,000 per year. The number of children with emotional/behavioral problems identified by the screens also more than tripled from about 6,000 per year to more than 20,000 per year. A separate set of analyses showed that referrals for mental health evaluations for children with Medicaid also increased significantly in Massachusetts at this time.

The study’s lead author, Karen Kuhlthau, PhD, of the MGHfC Center for Child and Adolescent Health Policy, says. “Increased screening is a first important step in assuring that children get the mental health services that they need.”

Study co-author Michael Murphy, EdD, MGH Psychiatry, says, “Childhood psychosocial issues are among the most common and disabling conditions of children and adolescents, both in this country and in the rest of the world. Routine screening as a part of well-child care can enable pediatricians to recognize problems sooner and to provide help, preferably at an earlier point in time when intervention would be more effective and/or less costly.”

This study primarily used the Pediatric Symptoms Checklist (PSC) as the mental health screening tool. Developed by the study’s authors at Massachusetts General Hospital, the PSC is a 35-item questionnaire given to parents at their child’s well-appointment visit. Parents check off NEVER, SOMETIMES, or OFTEN when asked questions pertaining to their child’s’ emotional and behavioral well being. Questions include whether a child “has school grades dropping,” “gets hurt frequently” or “acts younger than children his or her age.” The PSC can be easily scored to alert the pediatrician to a child’s likely emotional difficulties.

The PSC has been used throughout the United States for more than two decades, and just this past week, it received national recognition when it won the endorsement of the National Quality Forum, a voluntary organization that advises the federal and state governments on the best ways to measure outcomes. With NQF endorsement, the PSC may be used to evaluate parts of the new United States health care plan.

Additional co-authors of the Archives of Pediatrics and Adolescent Medicine report are Michael Jellinek, MD, chief of Psychiatry and Jeanne Van Cleave, MD, MassGeneral Hospital for Children; Gwyne White, Rutgers University; and Jack Simmons, PhD, Massachusetts Department of Health and Human Services. The costs of the study were paid for by a grant from The Fuss Family.

Material adapted from Massachusetts General Hospital.

The federally funded study involved 597 Finnish twins – 300 male and 297 female – who were assessed at ages 18 and 25.

“The key finding was that the more drinking-related problems experienced by an adolescent at age 18, the greater the likelihood that adolescent would be diagnosed with alcoholism seven years later at age 25,” said Richard Rose, professor emeritus at IU’s Department of Psychological and Brain Sciences and senior author of the article. “That predictive association was stronger in females than males. The analysis of co-twins ruled out factors such as parental drinking and household atmosphere as the source of the association because twins jointly experience these.”

Rose and his colleagues used the Rutgers Alcohol Problem Index (RAPI) to assess the twins at age 18. Seven years later they interviewed the twins using the Semi-Structured Assessment of the Genetics of Alcoholism to determine any alcohol abuse and dependent diagnoses.

RAPI is widely used to assess adolescent drinking-related problems, but this is the first time its predictive powers have been examined on a longitudinal basis. Rose said the findings have important implications for clinicians.

“The first step in intervention is to identify those at elevated risk,” he said. “Screening for drinking-related problems in adolescence may reliably identify many of those at elevated risk for development of alcoholism, and a self-report instrument such as RAPI offers an efficient approach for such screening.”

More about the study:

• RAPI is a self-report questionnaire on the frequency with which an adolescent has experienced 23 consequences of drinking alcohol, such as getting into a fight with a friend or family member, in the preceding 18 months.
• More drinking-related problems experienced at age 18 were associated with a diagnosis of alcohol dependence at age 25.
• The researchers were surprised by the strength of the association between RAPI scores and later alcohol dependence in females as well as in males, and in co-twins who differ in drinking, but share their childhood environments and half or all of their segregating genes
• Researchers found that some study participants with high RAPI scores did not become alcohol dependent and conversely some with low scores did, opening the door for further research.

Rather than reflecting a direct cause-and-effect relationship between adolescent drinking and adult alcoholism, the study findings, say some researchers, indicate the possibility that individuals who transgress social norms in adolescence by drinking heavily may be those same individuals who transgress social norms in adulthood by drinking abusively.

“I would say for sure that heavy drinking in adolescence is a real danger sign, regardless of whatever the causal mechanisms are,” said Matt McGue, professor in the Department of Psychology at the University of Minnesota. “Heavy drinking in adolescence is an indication that preventive intervention is warranted.”

Co-authors also included: Danielle M. Dick of Virginia Commonwealth University; Fazil Aliev of Virginia Commonwealth University and Ankara University, Turkey; Richard Viken of Indiana University; and Jaakko Kaprio of the University of Helsinki, and the National Public Health Institute, Finland.

Material adapted from Indiana University.

Additional Resources
Rutgers Alcohol Problem Index (RAPI) is copyright free instrument and available online. Visit The Center of Alcohol Studies (CAS) for additional information, including a free download.

Reference / Abstract
Danielle M. Dick, Fazil Aliev, Richard Viken, Jaakko Kaprio, & Richard J. Rose. Rutgers Alcohol Problem Index Scores at Age 18 Predict Alcohol Dependence Diagnoses 7 Years Later. Alcoholism: Clinical and Experimental Research. DOI: 10.1111/j.1530-0277.2010.01432.x

The research analyzed all of the available studies on driving after a stroke. In all of the studies, participants’ driving skills were tested in an on-road evaluation.

A total of 30 studies were analyzed. There were 1,728 participants with an average age of 61 years in the studies. Of those, 938 (54%) passed the on-road evaluation. The average amount of time between the stroke occurring and the on-road evaluation was about 9 months.

Three tests can be used to identify those people who are most at risk of failing the on-road driving test. The tests are a Road Sign Recognition test that assesses traffic knowledge and visual comprehension, a Compass task that examines visual-perceptual and visual-spatial abilities and mental speed, and the Trail Making Test B, which measures visual-motor tracking and visual scanning abilities.

“These are simple tests that can be done in the doctor’s office, which is important because on-road tests are time-consuming and expensive,” said study author Hannes Devos, MSc, of Catholic University of Leuven in Belgium. “These tests are readily available and can be administered within 15 minutes.”

People who score below 8.5 out of 12 on the road sign test, below 25 out of 32 on the compass test, and take more than 90 seconds to finish the trail making test are more likely to fail the on-road evaluation. The tests correctly classified 80 to 85 percent of the unsafe drivers.

The results also showed that participants’ fitness to drive could not be predicted by their motor symptoms. “This is not surprising considering the wide range of adaptive devices that are available, such as steering knobs that can be operated by one hand and left-foot accelerator pedals for people with limited use of the right leg,” Devos said.

In addition, the analysis found that 3 out of 4 studies showed no increased risk of accidents for people cleared to drive after a stroke.

Material adapted from American Academy of Neurology (AAN).

Drawing by a woman with anorexia. (Credit - Courtesy of the University of Haifa.)

The research, conducted by Prof. Lev-Wiesel alongside Dr. Jonathan Guez, Shimrit Valetsky, Dr. Diego Kruszewski Sztul and Dr. Bat-Sheva Pener, examined 76 women, 36 of whom had been diagnosed as anorexic or bulimic; 20 had no eating disorders but were overweight, and 20 had no eating disorders and were considered normal weight.

Self-figure drawing by a normal-weight woman. (Credit - Courtesy of the University of Haifa)

The research team then evaluated the drawings and found various differences between the groups in four aspects:

1. The neck: women suffering from anorexia or bulimia tended to draw a larger neck, a disconnected neck, or no neck at all;
2. The mouth: this feature was more emphasized in drawings by women suffering from anorexia or bulimia;
3. The thighs: women with eating disorders drew wider thighs than the other groups in the study;
4. The feet: women with eating disorders tended to draw pictures without feet or with disconnected feet.

Self-figure drawing by a woman suffering from bulimia. (Credit - Courtesy of the University of Haifa)

In order to assess the reliability of the drawing test, the more pronounced results were compared with the two standardized eating disorders screening tests, and a very strong correlation was found between all the tests.

“Women suffering from eating disorders usually tend to hide their condition, even from their professional therapists. They often find it difficult to talk about their problem so a non-verbal and non-intrusive tool such as a simple request for a self-figure drawing can become an important tool in creative art therapy,” explained Prof. Lev-Wiesel.

Material adapted from University of Haifa.

A comprehensive assessment of the wide spectrum of depressive symptomatology, particularly in its subclinical forms, is lacking in standard rating scales. There is also an emerging need for instruments that can detect small differences in therapeutic studies and have good sensitivity.

The purpose of this paper is to review the clinimetric (more on this term can be found here) characteristics of Paykel’s Clinical Interview for Depression (CID) and to examine the results of the studies in which the interview has been used. Published reports which involved the use of the CID were identified by searching the following electronic databases: Medline, PsychINFO, EMBASE, and Web of Science. A manual search of the literature was also performed. The initial strategies yielded 169 published reports for potential inclusion in the review of which 98 are discussed here.

The CID has been used extensively in a variety of studies, including descriptive studies, classification by means of factor analysis and cluster analysis, and predictor variables of response to treatment or relapse. The CID has also been used as an outcome measure in several controlled clinical trials and follow-up studies of pharmacotherapy and psychotherapy of affective disorders.

It has been shown to be valid and reliable, to discriminate depressives from controls, or different subgroups of depressed patients, and to reflect changes during the course of treatment, particularly when individual symptoms are considered. Evidence from these studies highlights the utility of the CID in clinical research and practice.

In summary, its clinimetric characteristics, particularly the broad evaluation of affective symptomatology and the sensitivity to change, make it an instrument of choice in therapeutic trials.

Material adapted from Journal of Psychotherapy and Psychosomatics.

Reference / Abstract
Guidi, J. ; Fava, G.A. ; Bech, P. ; Paykel, E. The Clinical Interview for Depression: A Comprehensive Review of Studies and Clinimetric Properties. Psychother Psychosom 2011;80:10-27

“Finding ways to prevent stroke and identify people at risk for stroke are important public health problems,” said study Letter. “This study shows we might get a better idea of who is at high risk of stroke by including a couple simple tests when we are evaluating people who already have some stroke risk.”

For the study, researchers gave tests to people age 45 and older who had never had a stroke, then contacted them twice a year by phone for up to 4.5 years to determine whether they had suffered a stroke. The average age of the participants was 67. Strokes were then confirmed by medical records. A total of 14,842 people took a verbal fluency test, measuring the brain’s executive functioning skills, and 17,851 people took a word recall memory test.

The study was part of a larger study called the REasons for Geographic and Racial Differences in Stroke (REGARDS) study. During the study, 123 participants who had taken the verbal fluency test and 129 participants who had taken the memory test experienced a stroke.

Those who scored in the bottom 20 percent for verbal fluency were 3.6 times more likely to develop a stroke than those who scored in the top 20 percent. For the memory test, those who scored in the bottom 20 percent were 3.5 times more likely to have a stroke than those in the top 20 percent. The difference in stroke incidence rates between those with the bottom and top 20 percent of scores was 3.3 strokes per thousand person-years. In general, the differences remained after researchers adjusted for age, education, race and where participants lived.

At age 50, those who scored in the bottom 20 percent of the memory test were 9.4 times more likely to later have a stroke than those in the top 20 percent, but the difference was not as large at older ages.

The study was supported by the National Institutes of Health and the National Institute of Neurological Disorders and Stroke.

Material adapted from American Academy of Neurology (AAN).

Led by Laura P. Richardson, MD, MPH, the team tested the PHQ-9 as a screening tool for depression in 442 teenage patients, age 13-17, at Group Health. The test is brief, available free of charge, easy to score and understand, and proven to find major depression (meeting DSM-IV criteria) in adults. This study, the first to assess it in teens, is in the November 2010 Pediatrics.

The Patient Health Questionnaire-9 (download below)

“This is important not only because depression is relatively common among adolescents, but also because we have effective treatment for them,” said Dr. Richardson. She is an associate professor of pediatrics at the UW, an adolescent medicine specialist at Seattle Children’s, and an affiliate investigator at Group Health Research Institute. “Primary care clinicians are advised to screen teens for depression,” she said, “and they need a convenient tool like this.”

The team compared the PHQ-9 to the more labor-intensive gold standard, an independent structured mental health interview (the Child Diagnostic Interview Schedule, DISC-IV)—and to published data on use of the screening test in adults. They found the best cut point for maximizing the PHQ-9 screening test’s sensitivity without losing specificity (11) is higher among teens than in adults. But its sensitivity (89.5%) and specificity (77.5%) in teens are similar to those in adults. So the team concluded that the PHQ-9 is an excellent choice for providers and researchers who want to screen for depression in teens in primary care.

Material adapted from Group Health Research Institute.

Download
PHQ-9 Form
PHQ-9 Administration/Scoring/Interpretation Manual (This is the adult manual. Please note the new appropriate cut-off score for adolescents described above.)

“Experts have long sought a clear behavioral marker of suicide risk,” says Harvard Professor of Psychology Matthew K. Nock, an author of two papers describing the new assessments of suicidal behavior. “The current approach, based on self-reporting, leads to predictions that are scarcely better than chance, since suicidal patients are often motivated to conceal or misrepresent their mental state. We sought to develop more sophisticated, objective measures of how psychiatric patients are thinking about suicide. Our work provides two important new tools clinicians can use in deciding how to treat potentially suicidal patients.”

Our work provides two important new tools clinicians can use in deciding how to treat potentially suicidal patients, said Harvard Professor of Psychology Matthew K. Nock (right), who worked on the study with Christine B. Cha (left), a doctoral student in psychology. (credit: Jon Chase/Harvard Staff Photographer)

Nock and colleagues report on the tests in two papers, one in the current Journal of Abnormal Psychology and a second published in Psychological Science. Unlike many previous efforts focused on biological markers of suicidal behavior, their work identifies two behavioral markers: subjects’ attention to suicide-related stimuli, and the extent to which they associate death or suicide with themselves.

In one study by Nock’s group, 124 patients in a psychiatric emergency department were administered a modified Stroop test measuring speed in articulating the color of words on a computer screen. Suicidal individuals were found to pay more attention to suicide-related words than to neutral words.

“Suicide Stroop scores predicted six-month follow-up suicide attempts above and beyond well-known risk factors such as a history of suicide attempts, patients’ reported likelihood of attempt, and clinicians’ predictions regarding patients’ likelihood of attempt,” says co-author Christine B. Cha, a doctoral student in psychology at Harvard.

A second study adapted the Implicit Association Test developed by Harvard psychologist Mahzarin R. Banaji, using reaction times to semantic stimuli to measure 157 subjects’ automatic mental associations – in this case, the strength of associations between words related to “self” and words related to either “life” or “death/suicide.” Participants were shown pairs of words on a screen, with response speed revealing unconscious associations between the terms. For instance, a rapid response to stimuli associating self with death/suicide suggests a strong unconscious association between the two.

Nock and his colleagues found that those participants with strong associations between self and death/suicide were six times more likely to attempt suicide within the next six months than those holding stronger associations between self and life.

“These findings suggest that a person’s implicit cognition may guide which behavior he or she chooses to cope with extreme distress,” Nock says. “More specifically, an implicit association with death/suicide may represent one of the final steps in the pathway to suicide.”

Material adapted from Harvard University.

PHQ-9 Overview
The PHQ-9 is a self-administered depression module of the Patient Health Questionnaire (PHQ). It contains 9 questions that help identify patients with clinically meaningful symptoms of depression. Patient responses are scored 0-3 with 0 representing “not at all” and 3 indicating “nearly every day;” thus, the PHQ-9 contains a total score range of 0-27 [1]. No specific administration time could be found, but a reasonable administration time is approximately 5-10 minutes for cognitively intact patients. PHQ-9 questions are straightforward and pertain to depressive symptoms experienced over the past 2 weeks that include anhedonia, dysphoria, sleep disturbances, fatigue, changes in eating, low self-esteem, concentration difficulties, hypo-or-hyper-active behaviors, and thoughts of suicide or homicide [1].

The PHQ-9 contains one additional question at the end of the form that asks, “How difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?” Possible answers range from “not difficult at all” to “extremely difficult” [1].

Scoring can often be accomplished within one minute [1]. Qualitative interpretation of scores is as follows:

Total Score / Qualitative Symptom Classification
1-4 / Minimal depression
5-9 / Mild depression
10-14 / Moderate depression
15-19 / Moderately severe depression
20-27 / Severe depression

Please review the PHQ-9 Administrative Manual for a more in-depth overview of interpretation of patient responses. Clinicians should obviously follow-up with a thorough clinical assessment if depression is detected, particularly if the patient endorses suicidal or homicidal ideation.

The Patient Health Questionnaire-9 (download available below)

PHQ-9 Psychometrics
The PQH-9 was administered to 6000 patients across 8 primary care and 7 obstetrics-gynecology (OBGYN) clinics. A cut-off score of 10 or greater produced a sensitivity of 88% and specificity of 88% for major depression. Internal reliability estimates range from .86 to 0.89 using Cronbach’s alpha. Two day test-retest reliability is estimated to be .84 with nearly identical mean total scores. The PHQ-9 demonstrated high correlation with another brief depression inventory, Mental Health Inventory (i.e., convergent validity) and higher PHQ-9 scores were related to overall decreased functional status, including more sick days and clinic visits [1].

Summary
The Patient Health Questionnaire-9 is valid, reliable, and cost effective psychological screening instrument for depression. Clinicians may reproduce the PHQ-9 free of charge and without fear of copyright violation. The PHQ-9 is intended to be used by clinicians or researchers in primary care settings. Health/Medical psychologists and physicians may find added confidence in the validity of this instrument given that PHQ-9 normative data is based on large patient samples from primary care and OBGYN settings. The PHQ-9 is useful particularly in busy medical offices or hospitals due to its easy-to-read format and brief administration, scoring, and interpretation.

Download The Patient Health Questionnaire – 9 (PHQ-9)
PHQ-9 Form
PHQ-9 Administration/Scoring/Interpretation Manual

Reference
[1] Kroenke, K., Spitzer, R., & Williams, J. (2001). The PHQ-9 validity of a brief depression severity measure. J GEN INTERN MED, 16, 606-613.

The specialized IBMP facility consists of interconnected modules serving as the mock interplanetary spaceship, including medical and scientific research areas, living quarters, a kitchen, greenhouse and exercise area. The chamber also contains a Mars landing vehicle module and a martian landscape module for simulated extravehicular activities.

Supported by National Space Biomedical Research Institute (NSBRI), the U.S. scientific team participating in the study is monitoring the six crew members’ rest-activity cycles, performance, and psychological responses to determine the extent to which sleep loss, fatigue, stress, mood changes, and conflicts occur during the mission.

“Extensive data from the Russian Mir Space Station, International Space Station and Apollo missions suggest that psychological and behavioral issues will be perhaps the greatest challenge humans will face when they embark on years-long missions to Mars and other locations,” said David F. Dinges, Ph.D., leader of NSBRI-funded group and a professor of psychology in psychiatry at the University of Pennsylvania School of Medicine.

The 520-day Mars Mission, conducted by IMBP under the auspices of the Russian Space Agency (Roscosmos), the Russian Academy of Sciences, and in cooperation with the European Space Agency, is the final phase of the Russian Mars 500 program. Previous phases included a 14-day test of the facility and a 105-day isolation study involving a six-man international crew in 2009. The 520-day mission is broken into 250 days for the trip to Mars, 30 days on the surface, and 240 days for the return to Earth.

During the simulation, Dinges and his colleagues are using miniaturized wristwatch-like devices to measure crew members’ sleep-wake patterns and specially programmed computers with brief assessment tests to gather information throughout the mission on crew members’ performance and emotions. Dinges is working in collaboration with Matthias Basner, M.D., from Penn, Dimitris Metaxas, Ph.D., of Rutgers University, and Daniel Mollicone, Ph.D., of Pulsar Informatics, Inc. Igor Savelev, Ph.D., NSBRI’s International Liaison, oversees the onsite implementation of the study and works in coordination with the Dinges team.

A key component of the computer-based assessment is the Psychomotor Vigilance Task (PVT) Self Test. This three-minute test measures the stability of sustained attention, psychomotor speed and impulsivity. PVT Self Test is also undergoing evaluation on the space station, where it is known as the Reaction Self Test.

“We’ve learned from laboratory experiments, other mission analogs and the Russian’s 105-day isolation study that the PVT is sensitive to fatigue and other factors that degrade the ability to pay attention and respond quickly,” said Dinges, who leads NSBRI’s Neurobehavioral and Psychosocial Factors Team.

PVT Self Test was developed through Dinges’ work with NSBRI, NASA, the Department of Defense and the National Institutes of Health. The user watches for a signal and responds when it appears, allowing the measurement of reaction times at a high degree of precision. Dinges also implemented PVT in studies involving astronauts in other space analog environments, such as on the ocean floor in NASA’s Extreme Environment Mission Operations (NEEMO) program.

“As soon as he completes the PVT Self Test, the crew member receives an assessment of how well the task was performed relative to someone who is fully alert and capable. The report also indicates how many times responses were too slow and how many times responses occurred before the signal came on,” Dinges said. “So, there is a measure of impulsivity as well as fatigue.”

Crew members do the assessment tests on their own specialized laptops programmed by Pulsar Informatics with built-in cameras to record facial expressions during testing. Facial video data will be evaluated off-line by computer algorithms developed in the Metaxas laboratory, where an optical computer recognition system is being created and validated in collaboration with Dinges for use in space to unobtrusively detect signs of sleepiness, negative moods and stress.

Every seventh day of the Mars 520-day mission simulation, the assessment tests are completed in the morning and before sleep. The tests take 10 minutes, requiring only 20 minutes of the crew member’s time on testing day, and include PVT Self Test and other measures of sleep quality/quantity, fatigue, stress, moods, conflict and depression.

“The crew is on a six-day work week. Because they take the test every seven days, we will get data from every day of their work cycle 14 times throughout the mission,” Dinges said.

For Dinges, the need to obtain data in this type of environment is essential.

“This simulated Mars mission is by far the longest-duration study of crew confinement under operating conditions attempted to date. It will have an impact on planning for exploration missions,” Dinges said. “It provides something we can’t learn from much shorter-duration simulations or from the 180-day stays on the space station: namely, what is the effect on crews of living and working for 520 days in continuous confinement?”

Mars 500 will allow Dinges and others to find out whether the ability to sleep well, attend to tasks, react quickly, maintain positive moods, and feel alert is sustainable across such a long mission, and whether there is evidence of negative moods, depression and an increase in conflicts.

The lessons learned extend to life on Earth.

“These tests and interventions have an impact beyond the space program,” said Dinges, a 2007 recipient of the NASA Distinguished Public Service Medal. “Many people, including those in military operations and many first responders, work night shifts and in high-stress, often confined environments that require alertness. The things we are learning about how to objectively and unobtrusively measure changes in performance and psychological status will be useful in many environments, such as power plant control rooms, railroad systems, emergency operations, hospitals, and police, fire and rescue situations.”

Material adapted from National Space Biomedical Research Institute by CFisher.

If you’re a man, how would you feel about being a subordinate employee to a high-powered and very assertive female manager? If you’re a woman searching for a reputable nanny, would you think twice about a male caretaker for your children, despite his exceptional references? Some people may be all for narrowing the gender gap, but when the issue hits close to home, being politically correct doesn’t come easy.

When it comes to their work life, women who took PsychTests’ gender roles test generally had more modern attitudes towards gender roles. Women were not only more comfortable with the idea of challenging traditional gender roles at work, but they were also more likely to act in accordance with their modern attitudes by, for example, wholeheartedly pursuing traditionally male positions, hiring women for traditional male positions or vice versa, or turning to a male colleague for emotional support and encouragement at work. Male test-takers, on the other hand, felt that there are certain job positions that are more appropriate for men (judge, carpenter, prison guard), and others more suited to women (nurse, administrative assistant). In addition, men are more likely to endorse stereotypic traits of how males behave at work, such as male employees are more “intimidating,” and more likely to “steal your ideas” than women are.

When PsychTests assessed men and women’s views on gender roles in the personal life realm, the opinions revealed a mix of modern and traditional opinions. Both men and women enjoy chivalry (who says it’s dead?), but the majority of men (53%) felt that they should pay for the first date, while the population of female test-takers had a variety of views, from going “Dutch” to suggesting that whoever initiated the date should pay. But it isn’t all knights in shining armor and damsels winking coquettishly. Both men and women added a modern twist, generally believing that it’s ok for a woman to ask a man out on a date – and to propose.

“These results are preliminary – we are still collecting data,” points out Dr. Jerabek. “But the initial results are already fascinating. We seem to be all over the place, with modern views in some situations and hanging onto traditional ones in others. For example, 67% of the men said that they don’t mind helping around the house, but 42% of men don’t like the idea that their lady might have had more sexual partners than they’ve had. And the stigma of being considered promiscuous if they initiate sex with a man is fading for women (only 2% of women think it’s inappropriate and 12% of men), but there are still some ladies out there (36%) who want to be fully taken care of financially by their men. So in the end, while we may think progressively, there are just some beliefs and preferences that die hard.”

An area in which men and women seemed to differ significantly was in their views on childhood gender roles. Men were more likely to encourage children to take on gender roles that are “appropriate” for them, particularly in regards to their own kids. It seems that some men are uncomfortable with the idea of their sons stepping away from what would be considered traditional hobbies and behaviors (e.g. choosing to play with dolls instead of more masculine toys), and more men than women (51% and 27% respectively) would actively discourage such behavior. A greater percentage of women than men would encourage their daughters to reach for any goal, despite it being considered more appropriate for boys, while more men than women (18% versus 6%) would teach their son that crying and whining is not acceptable behavior.

PsychTests’ statistical analysis also revealed that women are more comfortable with their femininity than men are with their manhood. In essence, women are more comfortable in that they don’t need to act like a woman in order to feel like a woman. For instance, most women were totally at ease with the idea of pursuing a career that defies tradition, of not getting married and having children, of being tomboyish, and would be fine making more money than their partner. Not to mention the fact that they feel equally feminine whether they’re wearing a ball gown or a pair of jeans! Contrarily, many men are less comfortable stepping away from what is considered stereotypical masculine behavior, and still uphold the idea that “macho” is equivalent to “masculine.” Many of the male test-takers felt that they would be less of a man if they lost their job and were unable to support their family (58%), or if they didn’t beat someone up for harassing their girlfriend/wife (77%). In addition, only 31% of men were comfortable with the idea of having gay friends.

Based on the results of their research, PsychTests believes there is no right or wrong when it comes to gender views, unless we try to force our opinions on others. The world is still moving forward, and while change is inevitable as the world progresses, there are some traditions that will be hard to drop. It’s all a matter of personal attitudes. So men, feel free to open the door for a woman even if she doesn’t say thank you, and ladies, reach for that brass ring and refuse that diamond one if you so choose to. As Oscar Wilde said, “Be yourself; everyone else is already taken.”

Take The Test
For women who wish to take the gender roles test, go here.
For men, go here.

Material adapted from PsychTests by CFisher.

Findings confirming the validity of the tool are reported in the current issue of the journal Alzheimer Disease and Associated Disorders.

Douglas Scharre, a neurologist at the Ohio State University Medical Center, developed the Self-Administered Gerocognitive Examination (SAGE) to help identify individuals with mild thinking and memory impairments at an early stage. The research shows four out of five people (80 percent) with mild thinking and memory (cognitive) issues will be detected by this test, and 95% of people who are normal thinking will have normal SAGE scores.

Scharre, who specializes in treating Alzheimer’s disease, said treatments for Alzheimer’s and dementia are more effective when they are introduced in the earliest stage of the disease. Unfortunately, he said he often sees patients more than three to four years after the first symptoms of a cognitive impairment began to appear.

“It’s a recurring problem,” said Scharre. “People don’t come in early enough for a diagnosis, or families generally resist making the appointment because they don’t want confirmation of their worst fears. Whatever the reason, it’s unfortunate because the drugs we’re using now work better the earlier they are started.”

Many of the assessment tools for cognitive disorders being used today, while accurate, have aspects that deter their use. “Seldom are physicians reimbursed for the time and effort it takes to give such tests, or they tie up personnel to physically administer the test,” said Scharre, who advocates the use of routine screening for cognitive disorders in the primary care setting. Other diagnostic tests require the patient to use a computer, which can add heightened anxiety to some older adults who may be infrequent users of technology.

The SAGE self-assessment is a practical tool for a busy primary care office,” added Scharre, who makes the tests available free of charge to healthcare personnel here. It only takes a paper, pen and a few minutes to take the test and because it’s self-administered, it doesn’t necessarily take time away from the appointment. “They can take the test in the waiting room while waiting for the doctor,” said Scharre.

Missing six or more points on the 22-point SAGE test usually warrants additional follow-up by the physician. Abnormal results can also prompt an early search for reversible and treatable conditions that may be causing the patient’s thinking and memory impairment. Many conditions besides Alzheimer’s disease, such as strokes and some thyroid conditions, can also impact memory, according to Scharre.

Scharre said there are potential cost savings to using the tests in a primary care setting. He reasons that a person who fares poorly on the self-exam will likely be less compliant taking medications on time, taking them in the proper dosages or following other recommendations such as maintaining healthy diets.

“Abnormal test results can serve as an early warning to the patient’s family,” added Scharre. “The results can be a signal that caregivers may need to begin closer monitoring of the patient to ensure their safety and good health is not compromised and that they are protected from financial predators.”

Results of the new test compare favorably with current standard cognitive assessments that are not self-administered. To validate the exam’s findings and accuracy, Scharre and other researchers at Ohio State evaluated study participants using SAGE, and then evaluated the same subjects with a battery of other established and well-documented assessment tools.

The study involved 254 study participants, 59 years of age or older, who took the SAGE self-assessment. Sixty-three (63) individuals were randomly selected to have a one-day clinical evaluation utilizing a battery of physical, neurological and cognitive tests.

SAGE scores compared favorably with the mini-mental state examination (MMSE), a brief questionnaire test that is commonly used in medicine to screen for cognitive impairments and dementia.

Both tests were able to differentiate clinically defined normal and mild cognitive improvement from subjects with dementia. However, SAGE, but not MMSE, was also able to distinguish between clinically defined normal from the mild cognitive improvement group.

Material adapted from Ohio State University by CFisher.

The study, which appears online this week in the journal Psychological Science, was led by Karen Campbell, a PhD student in psychology at the University of Toronto, with supervision from Rotman senior scientist Dr. Lynn Hasher, a leading authority in attention and inhibitory functioning in younger and older adults.

“We found that older brains are not only less likely to suppress irrelevant information than younger brains, but they can link the relevant and irrelevant pieces of information together and implicitly transfer this knowledge to subsequent memory tasks,” said Campbell.

In the study, 24 younger adults (17 – 29 years) and 24 older adults (60 – 73 years) participated in two computer-based memory tasks that were separated by a 10-minute break. In the first task, they were shown a series of pictures that were overlapped by irrelevant words (e.g. picture of a bird and the word “jump”). They were told to ignore the words and concentrate on the pictures only. Every time they saw the same picture twice in a row, they were to press the space bar. After completing this task and following a 10-minute break, they were tested on a “paired memory task” which essentially challenged them to recall how the pictures and words were paired together from the first task. They were shown three kinds of paired pictures – preserved pairs (pictures with overlap words that they saw in the first task), disrupted pairs (pictures they saw in the first task but with different overlap words) and new pairs (new pictures and new words they hadn’t seen before).

The older adults showed a 30% advantage over younger adults in their memory for the preserved pairs (the irrelevant words that went with the pictures in the first task) relative to the new pairs.

“This could be a silver lining to aging and distraction,” said Dr. Hasher, senior scientist on the study. “Older adults with reduced attentional regulation seem to display greater knowledge of seemingly extraneous co-occurrences in the environment than younger adults. As this type of knowledge is thought to play a critical role in real world decision- making, older adults may be the wiser decision-makers compared to younger adults because they have picked up so much more information.”

Material adapted from Baycrest Centre for Geriatric Care by CFisher.

Objectives
The primary objective of this study was to correlate patient satisfaction of a spinal implant for pain control with pre-surgery depression, age, gender, and an exaggerated emotional component to the pain as evident on the McGill Pain Questionnaire (MPQ) [7]. These variables were noted in the participant’s pre-surgical psychological evaluation and followed up with mailed questionnaires. This information contributes to the discussion on pre-implant psychological interventions to increase the chance of patient satisfaction. Implicit in this paradigm is increased communication between professionals and patients and ultimately a reduction in long-term health care costs.

Given that patients are an integral part of the health care paradigm, we need to understand their interaction and tailor approaches that increase patient satisfaction after implants and ultimately decrease overall medical utilization. Some questions that need to be explored include:

• What contributes to patient satisfaction?
• Why do some patients report miscommunication and unhappy interactions with providers
• Why do some patients suffer from emotional turmoil—either caused by or aggravated by their medical issues?
• What aspect of patient satisfaction is important to a patient’s perceived success of a surgical procedure.
• Why do some patients with the same physical condition improve while others did not? This understanding is an important step towards incorporating the proper treatments to encourage a positive surgical outcome.

Methods
This study utilized a quantitative approach to allow for an analysis of how depression, emotionality, age, and gender related to patient satisfaction after a surgery for a spinal implant. Out of the 120 potential participants randomly provided by a Pacific Northwest medical facility, sixty-two individuals participated in the survey; 26 (41.9%) participants were Male and 36 (58.1%) participants were Female. Sixty-two (100.0%) participants were Caucasian. Quantitative assessments of the pre-surgical evaluations and a follow-up mailed questionnaire derived a statistical analysis of these variables.

This was a retrospective study that tried to determine if any suspected risks affected the outcome of patient satisfaction. Due to the still-emerging literature on this relatively new procedure, retrospective studies have been widely used. For example, Horsch, Schulte, and Cologne [8] conducted a retrospective study that demonstrated a Spinal Cord Stimulator (SCS) was extremely beneficial in limb preservation in peripheral vascular disease. Retrospective continuous nonrandomized studies have their limitations and cannot be generalized beyond this population. However, they can serve as a preliminary analysis of the factors under study and help to guide future research projects.

Demographics
Descriptive analysis used frequency (number of occurrences out of total participants) and percentages for the nominal (categorical/dichotomous) data. In the study, 26 (41.9%) participants were male and 36 (58.1%) participants were female. All of the sixty-two (100.0%) participants were Caucasian. The target population was male and female adults (ages 36-83) who had a pre-implant psychological evaluation for a pain management device – spinal cord stimulator or an intrathecal pump – and were being treated at an Oregon medical clinic. The demographic data analyzed came from the post-surgery mailed questionnaire. The questions were designed to give insight to any extraneous variables that may have an impact on patient satisfaction.

The demographic variables are as follows: Thirty-one (50.0%) participants had a Spinal Cord Stimulator (SCS) Implant, 12 (19.4%) had an Intrathecal Pump Implant (IP), 12 (19.4%) had an Implant trial but did not proceed to full implantation, and seven (11.3%) decided not to get an implant after the pre-surgical psychological evaluation. Three (4.8%) participants were in pain for three to four years; four (6.5%) were in pain for five to six years; four (6.5%) were in pain for seven to eight years; and 51 (82.3%) were in pain for nine or more years.

Results
The results indicated that no significant relationship existed when comparing depression and patient satisfaction and also that depression did not significantly predict post-implant patient satisfaction. There was no significant relationship when comparing age group and patient satisfaction; gender and patient satisfaction; and McGill Pain Questionnaire results and patient satisfaction.

The results did show a positive correlation coefficient between a diagnosis of depression on the (pre-implant) and age at the time of surgery and the McGill Pain Questionnaire, number of years spent in pain prior to surgery, and number of previous surgeries. The findings showed that the older the patient was, the better coping mechanisms and less depression they had—perhaps because the older generation was raised in a time when pain was not dwelled upon as it is nowadays. Younger participants reported more depression, intense pain, and less effective coping skills than older participants of the same race. Miaskowski [9] points out the same inferences made by Erikson [10], namely, that the age at which chronic pain occurs impacts the individual as a function of interrupted life challenges and normal aging/life goals.

Thirty-one (50.0%) participants had fewer medical appointments after implantation, 19 (30.6%) had the same amount, and 12 (19.4%) endorsed not applicable due to not choosing to get the implant. Eight (12.9%) participants worked prior to their implant; eleven participants (17.7%) did not work prior to implant; twenty-nine (46.8%) participants were retired; and 14 (22.6%) participants were on Social Security Disability. Six (9.7%) participants returned to work after implant, 11 (17.7%) did not, and 45 (72.6%) participants endorsed not applicable. Forty-two (67.7%) participants still have the implant, 10 (16.2%) do not, and 10 (16.2%) endorsed not applicable because they had decided against having the implant after their participation in the pre-implant psychological evaluation.

Post-surgical pain patients who had experienced a reduction in their pain tended to be participants who were satisfied with the spinal implant for pain control. Overall, thirty-nine (62.9%) participants were satisfied with their implant and 16 (25.8%) were not satisfied. The latter group included some of those who decided not to proceed with the implant or decided after the first external trial of the device to not proceed to the full implant.

In this study, 50.9% of the participants reported 50% or more of pain relief, and 62.9% of participants expressed satisfaction of the spinal device. Overall, forty-two (68.9%) participants thought that the pre-surgical psychological evaluation was beneficial, and 19 (31.1%) did not.

Discussion
This study was implemented with the intention of understanding what contributes and correlates with patient satisfaction of a spinal implant for pain control. This study helped refine an emergent theory of the role of patient satisfaction in spinal implants and offers a contribution to current empirical knowledge. This study is meant to be a foundation for future studies, which must continue to refine the development of standard protocols for conducting psychological pre-implant evaluations and correlating variables to patient satisfaction. This author believes that the results of this study may lay a foundation upon which to begin building and testing additional theories on patient satisfaction of spinal implants for pain control.

Spinal cord stimulator vs. intrathecal pump
Participants who had a spinal cord stimulator or an intrathecal pump were put into the same category in this current study. Subsequent studies will need to decipher the differences between these two types of implants and contributing factors.

Ethnicity
It must be recognized that there is great ethnic variability in the chronic pain population. The majority of chronic pain sufferers in the Northwest are of Caucasian descent with the sample in this study being entirely Caucasian, but this is not true for all areas of the country. Each geographic location has its own distinct ethnic identity and future research needs to take this into account. Pain is impacted by a variety of biopsychosocial and cultural dimensions [11]. One must not downplay the role of culture and ethnicity to the pain experience. In today’s social climate, there is an increasing need for research sensitivity and responsibility to address the ethnicity correlates to the chronic pain experience. Within other geographical regions, it is important to develop culturally-appropriate assessments for patient satisfaction after spinal surgery for pain control – particularly when there may be significant differences in outcomes among those with differing ethnicities.

Sample size
Ideally, this small introductory non-randomized follow-up study will be replicated and expanded in the future with a greater number of participants. The results of this study cannot be generalized beyond this small patient population. This was just an initial followup study of the impact of a spinal cord stimulator for pain control relative to several variables as previously noted.

Summary
These results can be used to build presurgery protocols to enhance patient satisfaction and to eliminate unneeded biases for depression, age, gender, and emotional correlates to the pain experience. It is acknowledged by many professionals in the chronic pain research field that additional empirical evidence is needed to fully develop an understanding of the correlations between pre- and post-surgical psycho-social variables lending to patient satisfaction [4].

These results can help demonstrate the critical need for a multi-disciplinary language and understanding of this complex interplay of the bio-psycho-social aspects of chronic pain management. Physicians and psychologists will then be better able to implement an appropriate prevention and intervention programs that have been proven successful with chronic pain patients as well as gain additional insight when developing one of their own. Although the psychological evaluation is indicated prior to a trial of an implant, few studies have examined the relationship between psychological assessments and successful pain relief following a trial, and this should be an expanded focus of future research.

Terri A. Lechnyr, PhD

Practical Pain Management is a monthly journal that contains tutorial articles designed to help diagnose and treat various aspects of pain. This publication is sent free of charge to medical practitioners in the United States.

Material adapted (with permission) by CFisher from:
Lechnyr, T.A., (2009). Pre-implant psychological evaluations. Practical Pain Management, 9(1).

References (continued from Part 1):
4. Hale G. Pre-surgical psychological evaluations for implantable device. 2002. http://www.iwci.org/Clues02/June2002.htm Accessed 10/19/06.
5. Lechnyr R J and Lechnyr TA. Psychological
7. Melzach R. The McGill Pain Questionnaire. Churchill Livingston. 1975.
8. Horsch S, Schulte S, and Cologne D. Epidural spinal cord stimulation (SCS) in the treatment of peripheral vascular disease. Results of a retrospective study of 258 patients. 2006. http://isvs.vascularweb. org/ISVS_Contribution_Pages/Abstracts/2006/W C06_33.html. Accessed 4/22/06.
9. Miaskowski C. The impact of age on a patient=s perception of pain and ways it can be managed. Pain Management Nurse. 2000. 1(3): 2-7.
10. Erikson E. Childhood and Society. W. W. Norton & Company. 1963.
11. Melzach R and Wall P. Textbook of Pain. Churchill Livingston. 2005.

It is common practice for patients to have a psychological pre-implant evaluation by a qualified licensed psychologist in their home state before implantation. It is important to fully understand the significance of this psycho-educational-evaluative role as it relates to patient satisfaction and aiding in the selection of optimum preventative treatments. These assessments are not considered forensic evaluations, but ones that are both evaluative and educational in nature. The patient’s response to these interactions is important in determining their readiness for being active participants in the aspects of both pain management self-care skills and for the management of issues that may arise from their implant.

Psychologists and Pre-Implant Evaluations
Psychologists have a long history of involvement in the scientific research, assessment and treatment of various types of health care interventions. These range from assessing and improving the effectiveness of working with diabetic patients to the more present-day concern of the obesity epidemic[1]. Psychology also has a history of providing scientific research within the health care arena of biological, neurological, and behavioral medicine. Additionally, psychology has focused on issues faced by medical professionals and third-party payers who are concerned with utilization and over-utilization of health care. Physicians and surgeons are commonly coordinating care with psychologists to offer a unique perspective to complex health care concerns and work with pain patients issues in chronic pain clinics. Psychology has a central leading role as an adjunct to medical care [2].

Behavioral medicine/health psychologists who work with chronic pain patients seeking surgical implants have an obligation to assess and understand the impact of these interventions on patients to improve pre- and post-surgery outcomes. Therefore, Behavioral Health Psychologists have an obligation to understand the bio-psycho-social issues that impact the medical environment. They help to facilitate communication and education between all parties [3], in addition to providing cognitive behavioral pain management therapy to improve the patient’s ability to become active participants in active self-care techniques. Real pain management is a great deal more than just administering a particular type of medical intervention ranging from medications to surgical interventions. Due to the gravity of surgical implantation, it is expected that the psychologist conducting a pre-implant evaluation have a Doctorate in Psychology, is licensed in his or her state, and has a background working with chronic pain patients. They would also do well to have professional affiliations with pain organizations and have a background working with neurosurgery, neurology, or other pain related specialties [4].

The Goal of Pre-Implant Evaluations
When a surgical implant of a pain management device – such as a spinal cord stimulator or intrathecal pump – is indicated, important questions need to be answered. Besides looking to see if alternative approaches have first been tried, it is also important to select those patients who have the best chance of successfully responding to the surgical implant. We are all aware that some patients may not have the best results from surgery, even when all the physical findings are present to suggest the need for it.

The goal of a pre-implant evaluation is to determine which patients will have the best chance of a successful outcome and follow-up rehabilitation. Some patients will be poor responders to surgical intervention regardless of how successful the procedure may be. Others may have a better outcome if they have first received appropriate behavioral medicine treatments which make them more proactive in their recovery and subsequent rehabilitation. Some patients may first need help in identifying and eliminating issues in their lives that will interfere with their recovery.

It is important to note that the pre-implant psychological evaluation is not necessarily designed to eliminate candidates from surgical implantation. Rather it is designed to assist the surgeon, the patient, and the family in making appropriate decisions and treatment choices, depending on the particular needs of the patient. It focuses on the patient, personality style response patterns, personal life issues, issues that might result in setbacks, and other factors that are important to improved outcomes. Many medical patients are exhausted, confused, overwhelmed, not coping well, and need help in emotional stabilization prior to having any chance of using the medical interventions in an appropriate cost-effective manner.

At times, the evaluation may recommend surgical implantation, but with very specific recommendations for post-surgical rehabilitation and recovery interventions that will enhance the chance of the patient responding in a positive manner and quickly returning to a functional capacity. As such, the pre-implant psychological evaluation is a bio-psycho-social educational approach to helping patients make better use of the variety of treatment choices/options available. Many patients do not feel that they have more than a brief overview of what the entire process is all about. Therefore, education and information are a key focus of these evaluations.

Implant Evaluation Issues
Implant evaluation is part of a behavioral pain management approach to care. Evaluating patients for implants considers a number of factors including the patient’s:

• degree of understanding of the procedure;
• degree of understanding the need to be active in self-care;
• degree of understanding the need to make changes in usual methods of approaching life that may exacerbate pain problems;
• degree of understanding life-style changes that are required as part of participating in this procedure; and
• the ability to respond to this behavioral pain management evaluation in a manner that improves knowledge, skills, and active-skills

Those individuals who have been involved in any type of behavioral pain management treatment have the advantage of knowing many of the active self-care management techniques that must be employed on a regular daily basis in their lives. Their response to behavioral medicine treatment provides a great deal of information on how they can respond to long-term rehabilitation and management issues subsequent to an implant procedure for which they are being considered. Observed behavioral actions are always more reliable in any evaluation procedure. In this sense, part of the evaluation relies on the patient’s response to pre-implant treatment interventions.

Objectives
In health care, the final determination of whether or not a surgical procedure will be of help should be decided by the patient. The patient may sometimes be the neglected aspect in the provision of health care services and treated as secondary to the physician in the health care paradigm [5].  The health care model being proposed through this research study is based more on quality of care as measured by the patient. In psychological services, patients establish goals and then later report their level of attainment. Within the health psychology arena, the patient’s involvement should also be paramount [6].

Part 2:
In part 2 of this series, the results of a follow-up study of those patients who completed a pre-implant psychological evaluation and subsequently had an implant of a pain management device is covered.

Terri A. Lechnyr, Ph.D.

Practical Pain Management is a monthly journal that contains tutorial articles designed to help diagnose and treat various aspects of pain. This publication is sent free of charge to medical practitioners in the United States.

Material adapted (with permission) by CFisher from:
Lechnyr, T.A., (2009). Pre-implant psychological evaluations. Practical Pain Management, 9(1).

References
1.  Blackburn G and Kanders B. Obesity Pathophysiology Psychology and Treatment. Chapman Hall. New York. 1992.
2.  Sanders D. Counseling for psychosomatic problems. Sage. London. 1996.
3.  Williams D. Cognitive behavioral therapy: A strategy to assist in the management of fibromyalgia. Fibromyalgia Aware. 2003. 3: 22-27.
4.  Hale G. Pre-surgical psychological evaluations for implantable device. 2002. http://www.iwci.org /Clues02/June2002.htm Accessed 10/19/06.
5.  Lechnyr R J and Lechnyr TA. Psychological Dimensions of Pain Management. Practical Pain Management Journal. 2003. 3(4): 10-18.
6.  Baker T and Green C. Inter-race differences among black and white Americans presenting for chronic pain management: The influence of age, physical health, and psychosocial factors. Pain Medicine. 2005. 6: 29-38.

CES General Information
The CES-D is a 20-item self-report adult instrument designed to measure common symptoms of depression that have occurred over the past week, such as poor appetite, hopelessness, pessimism, and fatigue (Radloff, 1977). The CES-D takes approximately 5 minutes to complete. Questions are drawn from other depression inventories, such as the Zung Self-Rating Depression Scale (Zung SDS), the Beck Depression Inventory (BDI), and the Raskin Scale. All questions are answered on a scale of 0-3, with 0 indicating no symptom presence and with 3 representing symptoms “most or all of the time.” CES-D scores range from 0 to 60 with higher scores indicating more severe depressive symptoms. A score of 16 or higher identifies subjects with clinically meaningful depression (Radloff, 1977).

CES-D Psychometrics
Research demonstrates that the CES-D is valid and reliable instrument that can be used in research, and possibly clinical practice, to screen for common symptoms of major depression. The CES is particularly popular among researchers. Internal consistency using coefficient alpha is estimated to be .85 for the general population (healthy) and .90 in patient samples (Radloff, 1977). Most estimates of test-retest reliability from 2 weeks to 12 months fall in the moderate range (.45-.70); however, Radloff (1977) points out that moderate test-retest estimates are consistent with the CES-D’s design, which emphasizes current affective symptoms that are expected to fluctuate between test administrations. Researchers have also investigated the reliability and validity of the CES-D with African American, Asian American, French, Greek, Hispanic, Japanese, and Yugoslavian populations (Naughton and Wiklund 1993).

Summary
The CES-D is a cost effective, reliable, and valid screening instrument used to quickly assess the behavioral, cognitive, and affective symptoms of depression. The CES-D can be used without permission and is free of charge.

Download
Download the CES-D (Stanford Edition) CES-D Standford Version.

Reference:
Naughton MJ, & Wiklund I (1993). A critical review of dimension-specific measures of health-related quality of life in cross-cultural research. Qual Life Res 2:397–432.

Radloff, L. S. (1977). The CES-D scale: A self-report depression scale for research in the general population. Applied Psychological Measurement, 1, 385-401.

What is the The Pittsburgh Sleep Quality Index?
The Pittsburgh Sleep Quality Index (PSQI) is a freely available, brief (5 minutes), and reliable measurement of sleep quality and even includes a free scoring program (Microsoft Access required).

Why Measure Sleep?
Sleep problems commonly co-occur with anxiety, mood (especially depression and dysthymia), impulse-control, and substance abuse disorders. For example, persons with generalized anxiety disorder (GAD) are approximately three times (3x) more likely to report difficulty initiating sleep, problems maintaining sleep, and early morning awakening, and are six times (6x) more likely to experience non-restorative sleep (Roth et al., 2006). I have found it valuable to administer a pre/post sleep questionnaire whenever possible even if sleep is not an initial symptom complaint.

The Pittsburgh Sleep Quality Index Psychometrics
The PSQI (Buysse et al., 1989) is a 9-question, 19 item self-report instrument designed to measure sleep quality and disturbance over a 1-month period (Carpenter & Andrykowski, 1998). PSQI questions 1-4 request specific respondent information that is filled in by hand, such as customary bed time and length of time to fall asleep. PSQI questions 5-8 are answered on a 0-3 scale with 0 indicating no symptom presence and 3 representing symptom presence 3 or more times the past week. Question 9 is answered on a 0-3 scale with 0 meaning “very good” and 3 representing “very bad” (Carpenter & Andrykowski, 1998). All scores are combined according to the scoring criteria included with the form to produce a Global PSQI Score. Scores above 5 indicate clinically meaningfully disturbed or poor sleep.

Cronbach’s alpha coefficient produced an average internal consistency reliability estimate of .80 for the Global PSQI Score across numerous patient populations with a variety of different physical ailments (Carpenter & Andrykowski, 1998). Additionally, the PSQI is more highly correlated with sleep problems (r = .69 – .77) than with unrelated constructs, such as mood symptoms and depression (r = .22 – .65) (Carpenter & Andrykowski, 1998). Backhaus et al. (2002) reported an average Global PSQI Score test-retest reliability correlation coefficient of .87 in a group of 80 patients with primary insomnia over a test-retest interval of 2 days to 2 weeks. Additionally, Global PSQI Scores above 5 resulted in a sensitivity of 98.7% and specificity of 84.4% to persons with sleep disturbances versus controls (Backhaus et al., 2002).

Download:
Visit the University of Pittsburgh Sleep Medicine Institute to obtain the PSQI instrument, articles, and scoring program.

Christopher Fisher, PhD

References:
Backhaus, J., Junghanns, K., Broocks, A., Riemann, D. & Hohagen, F., (2002). Test-retest reliability and validity of the Pittsburgh Sleep Quality Index in primary insomnia. Journal of Psychosomatic Research, 53, 737– 740.

Buysse, D.J., Reynolds, C.F., Monk, T.H., Berman, S.R., & Kupfer, D.J. (1989). The Pittsburgh Sleep Quality Index (PSQI): A new instrument for psychiatric research and practice. Psychiatry Research, 28(2), 193-213.

Carpenter, J., & Andrykowski, M. (1998). Psychometric evaluation of the Pittsburgh Sleep Quality Index. Journal of Psychosomatic Research, 45(1), 5-13.

Roth, T., Jaeger, S., Jin, R., Kalsekar, A., Stang, P., & Kessler, R. (2006). Sleep problems, comorbid mental disorders, and role functioning in the National Comorbidity Survey Replication (NCS-R). Biological Psychiatry, December, 60(12), 1364-1371.

The field of psychology has a long and productive history of working with the military. Recall from Psychology 101 courses that our field gained traction and respect during World Wars 1 and 2 when asked to conduct formal tests of soldiers’ abilities. During World War I, the U.S. Army requested assistance from Robert Yakes – then president of the American Psychological Association (APA). In fact, these and other wars significantly increased interest in standardized achievement tests and fueled the development and acceptance of a number of different aptitude, personality, and intelligence tests, such as the Stanford-Benet Intelligence Scale, Stanford Achievement Test, Wechsler Intelligence Scale, and Woodworth Personal Data Sheet (personality inventory) (Kaplan & Saccuzzo, 2008).

The U.S. Army’s latest assessment initiative will undoubtedly provide new opportunities for psychologists that will hopefully again lead to great new developments in psychological assessment and mental health. Most important, of course, is that psychologists will have the chance to help the men and women of the armed services to improve their emotional health and quality of life.

Read the full story at the Christian Science Monitor here.

Enjoy.

CFisher

Reference:
Kaplan, R., & Saccuzzo, D. (2008). Psychological Testing: Principles, Applications, and Issues. Belmont: Wadsworth.

The test consists of 44 test items that take about 10 minutes to complete and was normed on thousands of adults. Check the online BFI manual for more details. The online scoring program is fairly easy to use with a succinct summary report of t-scores and percentages. Personality descriptions of low, medium, and high scores on each scale are provided.

Important note: Only healthcare professionals are allowed to sign up for a mandatory account required to access this personality instrument. Have your state healthcare license number handy too.

Download/Links:
Download the Big Five Inventory.
Visit The Big Five Inventory (online test/scoring program) here.
Visit the Test Master, Inc. (author’s site) website here.