Paul R. King

Psychometric study of the Neurobehavioral Symptom Inventory.

The Department of Veterans Affairs (VA) uses the Neurobehavioral Symptom Inventory (NSI) to measure postconcussive symptoms in its comprehensive traumatic brain injury (TBI) evaluation. This study examined the NSIs item properties, internal consistency, and external validity. Data were obtained from a federally funded study of the experiences of combat veterans. Participants included 500 Operations Iraqi and Enduring Freedom veterans, 219 of whom sustained at least one TBI. Data were collected at five VA medical centers and one VA outpatient clinic across upstate New York. Measures included neuropsychological interview, NSI, Beck Anxiety Inventory, Beck Depression Inventory-II, and Posttraumatic Stress Disorder Checklist-Military Version. The NSI demonstrated high internal consistency (total alpha = 0.95; subscale alpha = 0.88 to 0.92). Subscale totals based on Caplan et al.s factor analysis correlated highly with the NSI total score (r = 0.88 to 0.93). NSI scores differentiated veterans with TBI history from those without but were strongly influenced by variance associated with probable posttraumatic stress disorder, depression, and generalized anxiety. Results suggest that the NSI is a reliable and valid measure of postconcussive symptoms. Scale validity is evident in the differentiation of TBI and non-TBI classifications. The scale domain is not limited to TBI, however, and extends to detection of probable effects of additional affective disorders prevalent in the veteran population.

Establishing Measurement-based Care in Integrated Primary Care: Monitoring Clinical Outcomes Over Time

Full implementation of the patient-centered medical home requires the identification and treatment of patients with behavioral health concerns, leading to improved patient outcomes and reduced health care costs. Measurement-based care (MBC) for mental health conditions is an essential step in achieving these goals. Integrated primary care (IPC) administrators and providers are key leaders in MBC that spans initial screening for conditions to monitoring clinical outcomes over time. The purpose of this article is to assist IPC leaders, in partnership with their primary care team, in developing standard operating procedures for screening and follow up evaluations in order to lay a foundation for assessing program outcomes and improving quality of care in their unique settings.

Health service and medication use among veterans with persistent postconcussive symptoms.

Abstract Persistent postconcussive symptoms (PPCS) are noted when a series of cognitive, emotional, and somatosensory complaints persist for months after a concussion. Clinical management of PPCS can be challenging in the veteran population because of the nonspecific nature of symptoms and co-occurrence with affective disturbances such as posttraumatic stress disorder (PTSD) and chronic pain. In this study, we compared health service and medication use patterns in a sample of 421 veterans with PPCS with an age-matched cohort of case controls. The results suggest that the veterans with PPCS showed high rates of medical and mental health service utilization during a mean treatment period of 2 years. Although chronic pain commonly co-occurs with PPCS in veterans, service use and medication prescribing trends seem to have been influenced more by the presence of PTSD than chronic pain. Our findings reinforce the overlap among PPCS, PTSD, and chronic pain and demonstrate the complexity inherent in treating these conditions in veterans.

Using the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to identify practice patterns

Primary care-mental health integration (PC-MHI) is growing in popularity. To determine program success, it is essential to know if PC-MHI services are being delivered as intended. The investigation examines responses to the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ) to explore PC-MHI provider practice patterns. Latent class analysis was used to identify clusters of PC-MHI providers based on their self-report of adherence on the PPAQ. Analysis revealed five provider clusters with varying levels of adherence to PC-MHI model components. Across clusters, adherence was typically lowest in relation to collaboration with other primary care staff. Clusters also differed significantly in regard to provider educational background and psychotherapy approach, level of clinic integration, and previous PC-MHI training. The PPAQ can be used to identify PC-MHI provider practice patterns that have relevance for future clinical effectiveness studies, development of provider training, and quality improvement initiatives.

Self-Reported Pain and Pain Management Strategies Among Veterans With Traumatic Brain Injury: A Pilot Study

Reports of chronic pain such as headache, back and neck pain, and other musculoskeletal conditions are common among veterans with history of traumatic brain injury (TBI). This pilot study investigates self-reported pain and pain management strategies in a sample of veterans in postacute recovery from TBI. Participants included 24 outpatients with history of mild-to-moderate TBI who completed a series of self-report measures by mail, including the Pain Outcomes Questionnaire, the Pain Symptom Survey pain scale, and a detailed background survey. Seventy-nine percent of veterans surveyed reported frequent experiences with pain, typically headache, lower back, and joint pain of moderate severity. Two-thirds reported multiple pain locations, and more than half reported multiple concurrent mental health concerns, most frequently depression and post-traumatic stress disorder. Several different pain self-management strategies were identified with highly variable effects, though better perceived pain outcomes were reported with regular use of exercise and antidepressants. Many participants identified significant concerns regarding reinjury. Results suggest that opportunity exists for mental health professionals to address common anxieties pertaining to reinjury and to deliver concurrent interventions for chronic pain and affective disturbance.

The relationships among premilitary vocational aptitude assessment, traumatic brain injury, and postdeployment cognitive functioning in combat veterans.

Traumatic brain injury (TBI) in Iraq and Afghanistan war veterans is frequently associated with a variety of complaints, including cognitive problems and posttraumatic stress disorder. In this study, the authors explored the predictive impact of premilitary cognitive abilities on postdeployment cognitive functioning, as mitigated by posttraumatic stress symptoms in a sample of veterans with and without history of TBI. Measures included clinical interview, neuropsychological tests, the PTSD Checklist-Military Version, and the Armed Services Vocational Aptitude Battery. In contrast to history of TBI, premilitary abilities and posttraumatic stress symptoms emerged as significant predictors of postdeployment cognitive deficits.

Identifying measurement-based care practices of VHA co-located collaborative care providers.

The use of measurement-based care (MBC) is a routinely accepted practice in medical settings as a means to assess health status and guide evidence-based interventions. The continued expansion of integrated primary care within the Veterans Health Administration (VHA) offers ongoing opportunities for co-located collaborative care (CCC) providers to implement MBC. The present study aimed to identify and describe the degree to which MBC is used by CCC providers across VHA clinics in Upstate New York. A retrospective chart review of 448 CCC encounters was evaluated for evidence of MBC practices, including the use of quantitative mental health symptom screening tools, brief mental health symptom measures, and standardized functional assessment tools. Evidence of nonstandardized, idiographic assessments was also recorded. Providers’ use of measurement data to guide treatment initiation, modification, and termination was coded when available. Descriptive statistics were calculated for variables of interest. Results indicated that approximately 61% of patients were formally screened or completed mental health measures at least once during their course of care, though repeat administrations were rare. Detailed chart reviews found overall limited use of mental health screens and brief symptom measures (9.8% and 9.2% of all encounters, respectively), with measurement data infrequently (8.5%) linked to specific documented treatment decisions. Consistent with prior studies, CCC providers typically did not evidence use of standardized measures but did routinely record estimates of subjective distress and global functioning, lethality risk, and idiographic functional assessments. Obstacles and facilitators to the broader promotion and use of MBC among CCC providers are discussed.

Longitudinal study of objective and subjective cognitive performance and psychological distress in OEF/OIF Veterans with and without traumatic brain injury

Abstract Objective: To describe changes in post-deployment objective and subjective cognitive performance in combat Veterans over 18 months, relative to traumatic brain injury (TBI) status and psychological distress. Method: This prospective cohort study examined 500 Veterans from Upstate New York at four time points, six months apart. TBI status was determined by a structured clinical interview. Neuropsychological instruments focused on attention, memory, and executive functions. Subjective cognitive complaints were assessed with the Neurobehavioral Symptom Inventory (NSI). A psychological distress composite included measures of post-traumatic stress disorder (PTSD), depression, and generalized anxiety. Results: Forty-four percent of the sample was found to have sustained military-related TBI, 97% of which were classified as mild (mTBI), with a mean time since injury of 41 months. Veterans with TBI endorsed moderate cognitive symptoms on the NSI. In contrast to these subjective complaints, mean cognitive test performance was within normal limits at each time point in all domains, regardless of TBI status. Multilevel models examined effects of TBI status, time, and psychological distress. Psychological distress was a strong predictor of all cognitive domains, especially the subjective domain. Substantial proportions of both TBI+ and TBI− groups remained in the clinically significant range at the initial and final assessment for all three distress measures, but the TBI+ group had higher proportions of clinically significant cases. Conclusions: Objective cognitive performance was generally within normal limits for Veterans with mTBI across all assessments. Psychological distress was elevated and significantly related to both objective and subjective cognitive performance.

Identification and Management of Eating Disorders in Integrated Primary Care: Recommendations for Psychologists in Integrated Care Settings

Eating disorders are associated with deleterious health consequences, increased risk of mortality, and psychosocial impairment. Although individuals with eating disorders are likely to seek treatment in general medical settings such as primary care (PC), these conditions are often under-detected by PC providers. However, psychologists in integrated PC settings are likely to see patients with eating disorders because of the mental health comorbidities associated with these conditions. Further, due to their training in identifying risk factors associated with eating disorders (i.e., comorbid mental health and medical disorders) and opportunities for collaboration with PC providers, psychologists are well-positioned to improve the detection and management of eating disorders in PC. This paper provides a brief overview of eating disorders and practical guidance for psychologists working in integrated PC settings to facilitate the identification and management of these conditions.

Electronic Medical Record Documentation of Driving Safety for Veterans with Diagnosed Dementia

ABSTRACT Objectives: Many older adults continue to drive following dementia diagnosis, with medical providers increasingly likely to be involved in addressing such safety concerns. This study examined electronic medical record (EMR) documentation of driving safety for veterans with dementia (N = 118) seen in Veterans Affairs primary care and interdisciplinary geriatrics clinics in one geographic region over a 10-year period. Methods: Qualitative directed content analysis of retrospective EMR data. Results: Assessment of known risk factors or subjective concerns for unsafe driving were documented in fewer than half of observed cases; specific recommendations for driving safety were evident for a minority of patients, with formal driving evaluation the most frequently documented recommendation by providers. Conclusion: Utilizing data from actual clinical encounters provides a unique snapshot of how driving risk and safety concerns are addressed for veterans with dementia. This information provides a meaningful frame of reference for understanding potential strengths and possible gaps in how this important topic area is being addressed in the course of clinical care. Clinical Implications: The EMR is an important forum for interprofessional communication, with documentation of driving risk and safety concerns an essential element for continuity of care and ensuring consistency of information delivered to patients and caregivers.