Health Disparities and Recent Initiatives

Recent Initiatives Focused on Gender, Race, and Class

• Inequities exist in health and healthcare based on ethnicity, which is a well-known issue.
• National attention to these inequities has increased recently.
• Publications on mental health disparities have increased linearly from 2000 to 2007, with 180 publications in 2007.

Examples of Initiatives

• Healthy People 2020 aims to achieve health equity and eliminate disparities.
• Achieving the Promise: Transforming Mental Health Care in America outlines a plan to close the gap in access to quality mental health care for ethnic minorities.

Gender, Race, and Class and DSM-V

• DSM-V includes a "Cultural Formulation" to provide guidelines for understanding the cultural context of mental illness.
• Each diagnostic category includes "gender-related diagnostic issues" and/or "culture-related diagnostic issues" where relevant.

Role of Gender, Race, and Class in Diagnosis

• Diagnostic systems are not perfect, making it difficult to answer questions about gender, race, and class in diagnosis.
• Gender bias exists in diagnostic categories, such as antisocial personality disorder being more likely to be diagnosed in males.
• Race bias exists in the diagnosis of schizophrenia and psychotic affective disorders, with Black and Hispanic patients being more likely to be misdiagnosed.

Gender, Race, and Class Bias

• Gender bias exists in the diagnosis of antisocial personality disorder, with males being more likely to be diagnosed.
• Race bias exists in the diagnosis of schizophrenia and psychotic affective disorders, with Black and Hispanic patients being more likely to be misdiagnosed.
• Social class was not found to affect diagnoses.

Biased Diagnostic Constructs and Standards

• The DSM classification system represents an ethnocentric and culturally biased construction of what a non-pathological individual is.
• Women and individuals from collectivistic cultures are more likely to be diagnosed with a mental disorder due to cultural socialization and expectations.
• The DSM criteria for histrionic personality disorder are biased against women, with a focus on "inappropriately sexually seductive" behavior.

Biased Instruments of Assessment

• Diagnostic instruments can be biased due to differential item functioning, where test items have different measurement properties for different groups.
• Sex bias and gender bias can occur in self-report instruments, with masculine or feminine individuals being more likely to endorse certain items.

Biased Application of the Diagnostic Criteria

• Clinicians may be biased in making diagnoses, with a tendency to over-pathologize low-social-class individuals and diagnose race and gender biases.
• Lower-class African American patients are more likely to receive a diagnosis of chronic alcohol abuse than White lower-class or African American higher-class patients.

Biased Sampling

• Sampling biases can occur in clinical settings, where women and Whites may be more likely to seek treatment and have access to mental health care.

Role of Gender, Race, and Class in Treatment

• The majority of individuals with psychological disorders do not receive care, with women and Whites being more likely to seek mental health care.
• Men and African Americans are more likely to delay seeking treatment or seek care from primary care physicians.

Influence of the Client on Therapy Outcomes

• Higher socioeconomic status is related to staying longer in psychotherapy, while higher levels of education are related to longer treatment for substance abuse programs.
• Race and gender have a limited impact on therapy outcomes, with some studies finding African Americans gain less in therapy.

Client-Therapist Matching

• Matching clients with therapists of the same race or gender may improve outcomes, but results are mixed.

Gender, Race, and Class and Pharmacotherapy

• Exclusion of women and minorities from clinical trials has led to a lack of information about differential responses to psychopharmacological treatment.
• Race and sex may affect responses to drug treatment, with differences in absorption, distribution, metabolism, and elimination.

Understanding Gender, Race, and Class

• Chang (2003) presents two research perspectives for understanding differences in mental health and mental health care:
  • Discover and describe common factors that predict sociodemographic differences.
  • Assume that each group is embedded in a complex and unique set of historical, social, and cultural factors and that even when common factors are identified, each group may respond differently to them.

Conceptual Contributions

• Definition of culture: Beliefs and practices that pertain to a given ethnocultural group
• Limitations of this definition: Conceives of culture as residing largely within individuals and depicts culture as static and bounded
• Culture involves process and change, constantly in flux both in its regions of origin and as people move around the globe
• Two separate, but related goals of cultural research:
• Studying culture to identify general processes
• Studying culture to identify culture-specific processes

Major Advances

• Incorporation of cultural factors in DSM-IV and continued development of cultural issues in DSM-5
• Publication of the World Mental Health Report
• Release of the U.S. Surgeon General’s Supplemental Report on Mental Health: Culture, Race and Ethnicity
• Completion of the Collaborative Psychiatric Epidemiology Surveys (CPES)

Incorporation of Cultural Factors in DSM-IV/5

• National Institute of Mental Health (NIMH) funded the establishment of a Culture and Diagnosis Work Group
• The work group’s efforts resulted in three main contributions to DSM-IV:
• Inclusion of cultural factors in the expression, assessment, and prevalence of disorders in each of the disorder chapters
• An outline of a cultural formulation of clinical diagnosis to complement the multi-axial assessment
• A glossary of relevant cultural-bound syndromes from around the world
• Cultural considerations for DSM-5 build on the foundation provided by DSM-IV
• Cultural conceptions of distress in the DSM-5 are divided into three categories:
• Cultural syndromes
• Cultural idioms of distress
• Cultural explanation or perceived cause of illness
• DSM-5 includes the Cultural Formulation Interview, which is highly structured and usable by clinicians

Publication of the World Mental Health Report

• The report compiled research from across the world to identify the range of mental health and behavioral problems
• The most significant findings:
• Mental illness and related problems exact a significant toll on the health and wellbeing of people worldwide
• Mental illness produces a greater burden based on a "disability-adjusted life years" index than that from tuberculosis, cancer, or heart disease
• Depressive disorders alone were found to produce the fifth greatest burden for women and seventh greatest burden for men

Surgeon General’s Supplemental Report on Mental Health

• The report focused on the mental health of four main minority groups: American Indians/Alaska Natives, African Americans, Asian Americans/Pacific Islanders, and Latino Americans
• The main message was that “culture counts” and affects all aspects of mental health and illness

Collaborative Psychiatric Epidemiology Surveys (CPES)

• Comprises three nationally representative surveys:
• National Comorbidity Survey-Replication
• National Survey of American Life
• National Latino and Asian American Study
• The contributions of the CPES have been significant, providing nationally representative samples of three major U.S. racial/ethnic minority groups

Disorder-Related Research: Anxiety and Ataques de Nervios

• Ataque de nervios is an idiom of distress, particularly prominent among Latinos from the Caribbean
• Symptoms commonly associated with ataques de nervios include trembling, attacks of crying, screaming uncontrollably, and verbal or physical aggression
• Most episodes occur as a direct result of a stressful life event related to family or significant others
• Prevalence: 16% of the large community sample in Puerto Rico experienced ataques de nervios
• Ataques de nervios were found to be associated with a wide range of mental disorders, particularly anxiety and mood disorders

Disorder-Related Research: Schizophrenia

• The effect of schizophrenia on individuals and communities depends on whether they conceive of the self as autonomous and separate from others or as connected and bound to others
• Culture plays a role in the manner in which families respond to relatives with schizophrenia, which in turn influences the course of illness
• Expressed emotion: criticism, hostility, and emotional involvement
• Mexican American patients who returned to families marked by high warmth were less likely to relapse than those who returned to families characterized by low warmth

Conceptual Contributions

• Definition of culture: Beliefs and practices that pertain to a given ethnocultural group
• Limitations of this definition: Conceives of culture as residing largely within individuals and depicts culture as static and bounded
• Culture involves process and change, constantly in flux both in its regions of origin and as people move around the globe
• Two separate, but related goals of cultural research:
• Studying culture to identify general processes
• Studying culture to identify culture-specific processes

Major Advances

• Incorporation of cultural factors in DSM-IV and continued development of cultural issues in DSM-5
• Publication of the World Mental Health Report
• Release of the U.S. Surgeon General’s Supplemental Report on Mental Health: Culture, Race and Ethnicity
• Completion of the Collaborative Psychiatric Epidemiology Surveys (CPES)

Incorporation of Cultural Factors in DSM-IV/5

• National Institute of Mental Health (NIMH) funded the establishment of a Culture and Diagnosis Work Group
• The work group’s efforts resulted in three main contributions to DSM-IV:
• Inclusion of cultural factors in the expression, assessment, and prevalence of disorders in each of the disorder chapters
• An outline of a cultural formulation of clinical diagnosis to complement the multi-axial assessment
• A glossary of relevant cultural-bound syndromes from around the world
• Cultural considerations for DSM-5 build on the foundation provided by DSM-IV
• Cultural conceptions of distress in the DSM-5 are divided into three categories:
• Cultural syndromes
• Cultural idioms of distress
• Cultural explanation or perceived cause of illness
• DSM-5 includes the Cultural Formulation Interview, which is highly structured and usable by clinicians

Publication of the World Mental Health Report

• The report compiled research from across the world to identify the range of mental health and behavioral problems
• The most significant findings:
• Mental illness and related problems exact a significant toll on the health and wellbeing of people worldwide
• Mental illness produces a greater burden based on a "disability-adjusted life years" index than that from tuberculosis, cancer, or heart disease
• Depressive disorders alone were found to produce the fifth greatest burden for women and seventh greatest burden for men

Surgeon General’s Supplemental Report on Mental Health

• The report focused on the mental health of four main minority groups: American Indians/Alaska Natives, African Americans, Asian Americans/Pacific Islanders, and Latino Americans
• The main message was that “culture counts” and affects all aspects of mental health and illness

Collaborative Psychiatric Epidemiology Surveys (CPES)

• Comprises three nationally representative surveys:
• National Comorbidity Survey-Replication
• National Survey of American Life
• National Latino and Asian American Study
• The contributions of the CPES have been significant, providing nationally representative samples of three major U.S. racial/ethnic minority groups

Disorder-Related Research: Anxiety and Ataques de Nervios

• Ataque de nervios is an idiom of distress, particularly prominent among Latinos from the Caribbean
• Symptoms commonly associated with ataques de nervios include trembling, attacks of crying, screaming uncontrollably, and verbal or physical aggression
• Most episodes occur as a direct result of a stressful life event related to family or significant others
• Prevalence: 16% of the large community sample in Puerto Rico experienced ataques de nervios
• Ataques de nervios were found to be associated with a wide range of mental disorders, particularly anxiety and mood disorders

Disorder-Related Research: Schizophrenia

• The effect of schizophrenia on individuals and communities depends on whether they conceive of the self as autonomous and separate from others or as connected and bound to others
• Culture plays a role in the manner in which families respond to relatives with schizophrenia, which in turn influences the course of illness
• Expressed emotion: criticism, hostility, and emotional involvement
• Mexican American patients who returned to families marked by high warmth were less likely to relapse than those who returned to families characterized by low warmth

Classification Systems

• Current classification systems include the 5th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the 10th edition of the World Health Organization's (WHO) International Classification of Diseases (ICD-10).
• The DSM-5 and ICD-10 are largely congruent nomenclatures, with the primary distinction being that the ICD-10 has two versions, one for clinicians and one for researchers.

World Health Organization

• The United States, as a member of the WHO, is required to use the coding system of the ICD.
• The code numbers used in all clinics and hospitals within the United States (and included within DSM-5) are the ICD code numbers.
• Each member country of the WHO can modify the diagnostic criteria for a respective disorder as long as the modification does not result in an entirely different disorder.
• Each country can also decline to include a particular disorder within its version of the ICD or add a disorder to its own version of the ICD that is not included in the ICD.

Early History

• The Statistical Manual for the Use of Institutions for the Insane (1918) was developed by the American Medico-Psychological Association (later renamed to the American Psychiatric Association).
• The manual failed to gain widespread acceptance and included only 22 diagnoses.
• Psychiatric disorders within the American Medical Association's Standard Classified Nomenclature of Disease were developed by the New York Academy of Medicine in 1928, but it eventually proved to be inadequate.

ICD-6 and DSM-I

• World War II convinced the profession that a common language of psychopathology was needed, leading to the production of the 6th edition of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6) by the WHO in 1948.
• The United States Public Health Service commissioned a committee to create a nomenclature based upon the ICD-6, resulting in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952.

ICD-8 and DSM-II

• ICD-6 was revised to ICD-7 in 1955, but there were no revisions to the mental disorders.
• In 1965, the American Psychiatric Association appointed a committee to revise DSM-I to be compatible with ICD-8 and suitable for use within the United States, resulting in DSM-II in 1968.
• A fundamental problem continued to be the absence of empirical support for the reliability and validity of its diagnoses.

ICD-9 and DSM-III

• The authors of ICD-9 included a glossary that provided more precise descriptions of each disorder.
• The ICD-9 did not include the more specific and explicit criterion sets used in research.
• DSM-III was published in 1980, including specific and explicit criterion sets for all but one of the disorders, a substantially expanded text discussion of each disorder, and removal of terms that appeared to favor a particular theoretical model for the disorder's etiology or pathology.

DSM-III-R

• Many problems in DSM-III were due to insufficient research to guide the authors of the criterion sets.
• The American Psychiatric Association authorized the development of a revision to DSM-III to make corrections and refinements.
• Many proposals for new diagnoses were made, including sadistic personality disorder, self-defeating personality disorder, premenstrual dysphoric disorder, and paraphiliac rapism.

DSM-IV

• The DSM-IV committee aspired to use a more conservative threshold for the inclusion of new diagnoses and to have decisions guided more explicitly by the scientific literature.
• Proposals for additions, deletions, or revisions were guided by 175 literature reviews that used a required format that maximized the potential for critical review.

DSM-IV-TR

• DSM-IV-TR included a relatively detailed text discussion of each disorder, including information on age of onset, gender, course, and familial pattern.
• The text was expanded to include cultural and ethnic group variation, variation across age, and laboratory and physical exam findings.
• Information concerning etiology, pathology, and treatment was largely excluded from the text.

DSM-5

• Published in 2013, DSM-5 generated a substantial body of controversy.
• Many new disorders were added, including disruptive mood dysregulation disorder, excoriation disorder, hoarding disorder, illness anxiety disorder, premenstrual dysphoric disorder, and binge eating disorder.

Issues with DSM-5

• Empirical support for proposed revisions was inadequate.
• The definition of mental disorder has been criticized for expanding into normal problems of living.
• Diagnostic criteria can have different implications and meanings across different cultures.
• The impact of values and cultural issues is a concern.
• The shifting to a neurobiological model excludes cognitive, psychodynamic, or interpersonal-systems clinicians.
• The shift to a dimensional model is a significant change from the categorical classification of DSM-IV.

Classification Systems

• Current classification systems include the 5th edition of the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-5) and the 10th edition of the World Health Organization's (WHO) International Classification of Diseases (ICD-10).
• The DSM-5 and ICD-10 are largely congruent nomenclatures, with the primary distinction being that the ICD-10 has two versions, one for clinicians and one for researchers.

World Health Organization

• The United States, as a member of the WHO, is required to use the coding system of the ICD.
• The code numbers used in all clinics and hospitals within the United States (and included within DSM-5) are the ICD code numbers.
• Each member country of the WHO can modify the diagnostic criteria for a respective disorder as long as the modification does not result in an entirely different disorder.
• Each country can also decline to include a particular disorder within its version of the ICD or add a disorder to its own version of the ICD that is not included in the ICD.

Early History

• The Statistical Manual for the Use of Institutions for the Insane (1918) was developed by the American Medico-Psychological Association (later renamed to the American Psychiatric Association).
• The manual failed to gain widespread acceptance and included only 22 diagnoses.
• Psychiatric disorders within the American Medical Association's Standard Classified Nomenclature of Disease were developed by the New York Academy of Medicine in 1928, but it eventually proved to be inadequate.

ICD-6 and DSM-I

• World War II convinced the profession that a common language of psychopathology was needed, leading to the production of the 6th edition of the International Statistical Classification of Diseases, Injuries, and Causes of Death (ICD-6) by the WHO in 1948.
• The United States Public Health Service commissioned a committee to create a nomenclature based upon the ICD-6, resulting in the American Psychiatric Association's Diagnostic and Statistical Manual of Mental Disorders (DSM-I) in 1952.

ICD-8 and DSM-II

• ICD-6 was revised to ICD-7 in 1955, but there were no revisions to the mental disorders.
• In 1965, the American Psychiatric Association appointed a committee to revise DSM-I to be compatible with ICD-8 and suitable for use within the United States, resulting in DSM-II in 1968.
• A fundamental problem continued to be the absence of empirical support for the reliability and validity of its diagnoses.

ICD-9 and DSM-III

• The authors of ICD-9 included a glossary that provided more precise descriptions of each disorder.
• The ICD-9 did not include the more specific and explicit criterion sets used in research.
• DSM-III was published in 1980, including specific and explicit criterion sets for all but one of the disorders, a substantially expanded text discussion of each disorder, and removal of terms that appeared to favor a particular theoretical model for the disorder's etiology or pathology.

DSM-III-R

• Many problems in DSM-III were due to insufficient research to guide the authors of the criterion sets.
• The American Psychiatric Association authorized the development of a revision to DSM-III to make corrections and refinements.
• Many proposals for new diagnoses were made, including sadistic personality disorder, self-defeating personality disorder, premenstrual dysphoric disorder, and paraphiliac rapism.

DSM-IV

• The DSM-IV committee aspired to use a more conservative threshold for the inclusion of new diagnoses and to have decisions guided more explicitly by the scientific literature.
• Proposals for additions, deletions, or revisions were guided by 175 literature reviews that used a required format that maximized the potential for critical review.

DSM-IV-TR

• DSM-IV-TR included a relatively detailed text discussion of each disorder, including information on age of onset, gender, course, and familial pattern.
• The text was expanded to include cultural and ethnic group variation, variation across age, and laboratory and physical exam findings.
• Information concerning etiology, pathology, and treatment was largely excluded from the text.

DSM-5

• Published in 2013, DSM-5 generated a substantial body of controversy.
• Many new disorders were added, including disruptive mood dysregulation disorder, excoriation disorder, hoarding disorder, illness anxiety disorder, premenstrual dysphoric disorder, and binge eating disorder.

Issues with DSM-5

• Empirical support for proposed revisions was inadequate.
• The definition of mental disorder has been criticized for expanding into normal problems of living.
• Diagnostic criteria can have different implications and meanings across different cultures.
• The impact of values and cultural issues is a concern.
• The shifting to a neurobiological model excludes cognitive, psychodynamic, or interpersonal-systems clinicians.
• The shift to a dimensional model is a significant change from the categorical classification of DSM-IV.

Psychometric Principles: Reliability

• Reliability refers to the consistency of measurement
• There are several ways to evaluate reliability:
  • Internal consistency: Test items should be positively intercorrelated
  • Test-retest reliability: Similar scores should be obtained on separate administrations of the test
  • Interrater reliability: Different psychologists should tend to agree on diagnoses or judgments

Psychometric Principles: Validity

• Validity refers to the accuracy of interpretations and judgments
• Types of validity:
  • Content validity: Evidence based on test content
  • Convergent validity: Moderate or high correlations with other tests that measure the same attribute or diagnosis
  • Discriminant validity: Low correlations with tests that measure other attributes
  • Predictive validity: Test scores are used to forecast future outcomes
  • Concurrent validity: Scores are correlated with indices or events measured at approximately the same time
  • Incremental validity: The extent to which an instrument contributes information above and beyond already available information

Psychometric Principles: Difference Between Reliability and Validity

• Reliability refers to the consistency of test scores and judgments
• Validity refers to the accuracy of interpretations and judgments
• Good reliability does not equal good validity

Psychometric Principles: Treatment Utility

• Describes the extent to which an assessment instrument contributes to decisions about treatment that lead to better outcomes
• An assessment instrument could have good validity and good incremental validity, yet not lead to improved treatment outcome

Signal Detection Theory (SDT)

• A statistical approach used when the task is to detect a signal, such as the presence of major depression in a client
• Can describe the validity of an assessment instrument across all base rates and across all cutoff scores

Norms

• Scores that provide a frame of reference for interpreting a client's results
• In the assessment of psychopathology, normative data can be collected by administering a test to a representative sample of individuals in the community

Interviews

• Unstructured interviews are used predominantly in clinical practice
• Structured and semi-structured interviews are used predominantly in research, but are being used increasingly in clinical care
• Reliability of diagnoses using the DSM:
  • Good interrater reliability for some diagnostic categories
  • Unacceptable reliability for others

Interviews: Validity

• Structured interviews are on average more valid than unstructured interviews

Interviews: Limitations

• It is relatively easy for respondents to consciously underreport or overreport psychopathology on structured interviews
• Reports in interviews are often inaccurate or incomplete, even when clients are not intentionally trying to deceive the interviewer
• Considerable clinical judgment is required to describe and diagnose the client because information from different sources must be integrated

Brief Self-Rated and Clinician-Rated Measures

• Developed for monitoring psychotherapy progress and providing information necessary for delivering standardized evidence-based interventions
• Reliability and validity of many of these measures appears to be adequate, but evaluation of their validity has been limited

Behavioral Assessment Methods

• Diary measures can provide accurate information about symptoms and behaviors
• Cell phones have made it easier to collect and analyze self-monitoring data

Psychophysiological Assessment

• Polysomnographic evaluation can provide valuable information about sleep patterns
• Measures of psychophysiological arousal can provide important information in the assessment of posttraumatic stress disorder

Global Measures of Personality and Psychopathology

• Projective techniques:
  • Designed to measure broad aspects of personality and psychopathology
  • Include the Rorschach, Thematic Apperception Test (TAT), and human figure drawings
  • Problems: reliable scoring is often difficult to achieve, and normative data have often been unavailable or inaccurate
• Self-report personality inventories:
  • Require clients to indicate whether a statement describes them
  • Relatively structured, with clear stimuli and constrained response formats
  • Include the Minnesota Multiphasic Personality Inventory-2, the Personality Assessment Inventory, and the Millon Clinical Multiaxial Inventory-III
  • Validity of primary scales of some tests has generally been supported, but validity evidence for scales of other widely used tests is weaker and less consistent

Clinical Judgment and Decision Making

• Clinicians often do not benefit from experience due to:
  • Lack of clearcut feedback concerning their judgments and predictions
  • Vague and ambiguous feedback
  • Limited access to necessary data
  • Misleading feedback from clients
• Cognitive biases:
  • Confirmatory bias
  • Premature closure
• Group biases in judgment:
  • Sex bias
  • Race bias
  • Social class bias

Psychometric Principles: Reliability

• Reliability refers to the consistency of measurement
• There are several ways to evaluate reliability:
  • Internal consistency: Test items should be positively intercorrelated
  • Test-retest reliability: Similar scores should be obtained on separate administrations of the test
  • Interrater reliability: Different psychologists should tend to agree on diagnoses or judgments

Psychometric Principles: Validity

• Validity refers to the accuracy of interpretations and judgments
• Types of validity:
  • Content validity: Evidence based on test content
  • Convergent validity: Moderate or high correlations with other tests that measure the same attribute or diagnosis
  • Discriminant validity: Low correlations with tests that measure other attributes
  • Predictive validity: Test scores are used to forecast future outcomes
  • Concurrent validity: Scores are correlated with indices or events measured at approximately the same time
  • Incremental validity: The extent to which an instrument contributes information above and beyond already available information

Psychometric Principles: Difference Between Reliability and Validity

• Reliability refers to the consistency of test scores and judgments
• Validity refers to the accuracy of interpretations and judgments
• Good reliability does not equal good validity

Psychometric Principles: Treatment Utility

• Describes the extent to which an assessment instrument contributes to decisions about treatment that lead to better outcomes
• An assessment instrument could have good validity and good incremental validity, yet not lead to improved treatment outcome

Signal Detection Theory (SDT)

• A statistical approach used when the task is to detect a signal, such as the presence of major depression in a client
• Can describe the validity of an assessment instrument across all base rates and across all cutoff scores

Norms

• Scores that provide a frame of reference for interpreting a client's results
• In the assessment of psychopathology, normative data can be collected by administering a test to a representative sample of individuals in the community

Interviews

• Unstructured interviews are used predominantly in clinical practice
• Structured and semi-structured interviews are used predominantly in research, but are being used increasingly in clinical care
• Reliability of diagnoses using the DSM:
  • Good interrater reliability for some diagnostic categories
  • Unacceptable reliability for others

Interviews: Validity

• Structured interviews are on average more valid than unstructured interviews

Interviews: Limitations

• It is relatively easy for respondents to consciously underreport or overreport psychopathology on structured interviews
• Reports in interviews are often inaccurate or incomplete, even when clients are not intentionally trying to deceive the interviewer
• Considerable clinical judgment is required to describe and diagnose the client because information from different sources must be integrated

Brief Self-Rated and Clinician-Rated Measures

• Developed for monitoring psychotherapy progress and providing information necessary for delivering standardized evidence-based interventions
• Reliability and validity of many of these measures appears to be adequate, but evaluation of their validity has been limited

Behavioral Assessment Methods

• Diary measures can provide accurate information about symptoms and behaviors
• Cell phones have made it easier to collect and analyze self-monitoring data

Psychophysiological Assessment

• Polysomnographic evaluation can provide valuable information about sleep patterns
• Measures of psychophysiological arousal can provide important information in the assessment of posttraumatic stress disorder

Global Measures of Personality and Psychopathology

• Projective techniques:
  • Designed to measure broad aspects of personality and psychopathology
  • Include the Rorschach, Thematic Apperception Test (TAT), and human figure drawings
  • Problems: reliable scoring is often difficult to achieve, and normative data have often been unavailable or inaccurate
• Self-report personality inventories:
  • Require clients to indicate whether a statement describes them
  • Relatively structured, with clear stimuli and constrained response formats
  • Include the Minnesota Multiphasic Personality Inventory-2, the Personality Assessment Inventory, and the Millon Clinical Multiaxial Inventory-III
  • Validity of primary scales of some tests has generally been supported, but validity evidence for scales of other widely used tests is weaker and less consistent

Clinical Judgment and Decision Making

• Clinicians often do not benefit from experience due to:
  • Lack of clearcut feedback concerning their judgments and predictions
  • Vague and ambiguous feedback
  • Limited access to necessary data
  • Misleading feedback from clients
• Cognitive biases:
  • Confirmatory bias
  • Premature closure
• Group biases in judgment:
  • Sex bias
  • Race bias
  • Social class bias

Psychotherapy Research

• Psychotherapy research is a broad field that encompasses multiple streams of research, including process research, outcome research, and randomized controlled trials (RCTs).

Process Research

• Focuses on identifying and delineating important events in therapy.
• Examines what happens in a therapeutic session, including variables such as therapist behaviors, client behaviors, and interactions between the therapist and client.
• Linked to outcome research to identify factors that may be important in treatment outcome.

Outcome Research

• Focuses on the effects of psychotherapy, including immediate and long-term changes in the problems for which a person seeks treatment.
• Examines improvement on broader variables such as quality of life or interpersonal functioning.

Randomized Controlled Trials (RCTs)

• Patients are randomly assigned to the treatment of interest or to one or more control groups or alternative treatments.
• Random assignment helps to eliminate systematic pre-existing differences among patients.

Control Groups

• Used to determine whether any improvement with treatment might be due to factors such as the passage of time, assessment procedures, or making a decision to do something about the problem.
• Types of control groups include:
  • Waiting list control conditions: clients receive the treatment under investigation after a prescribed delay.
  • Placebo controlled conditions: e.g., a pill placebo combined with regular brief meetings with a supportive psychiatrist.
  • Alternative therapy conditions: e.g., supportive counseling.

Empirically Validated/Supported Treatments

• Refer to treatments that have met the standards set by one or more groups who have reviewed the psychotherapy literature to identify treatments that work for particular disorders or presenting problems.
• ESTs can be categorized as probably efficacious or efficacious, based on the number of studies that have shown their superiority to waiting list control groups or placebo conditions.

Effectiveness Research

• Focuses on testing whether a treatment works in the real world, with the sorts of patients who may not have participated in university-based research trials.
• Often involves less tightly controlled designs and may be simple pretest-posttest studies with no control group.
• Benchmarking may be used to compare results to those in published efficacy research.

Criticism of ESTs

• The claim is often made that ESTs will not work in clinical practice settings because the clients in practice settings are possibly more severe or have more comorbid conditions than clients treated in research studies.
• Westen and Morrison (2001) estimated that the average inclusion rate for studies of depression, panic disorder, and generalized anxiety disorder ranged from 32−36%.

Anxiety Disorders

• Generalized anxiety disorder has a lifetime prevalence of 3.3%.
• Anxiety disorders are relatively common in older adults, but relatively few people experience a first onset episode in late life.
• Older adults tend to report less frequent negative emotions compared to younger adults.
• Phobias and panic attacks often co-occur with physical illnesses, which are more common among older adults.

Anxiety: Etiology

• Biological factors contributing to anxiety in older adults include chronic health conditions and hypertension.
• Psychological factors include external locus of control and neuroticism.
• Social factors include quality of social support.

Anxiety: Explanation for Age Differences

• Developmental changes in social, familial, and occupational roles may impact the manifestation of anxiety symptoms in older adults.
• Older adults may experience less anxiety later in life due to improvements in emotion regulation skills.

Mood Disorders

• Depression is a leading cause of disability and is associated with elevated risk of mortality in older adults.
• Bipolar disorder is relatively rare in older adults, affecting 0.5-1% of the population.
• At least half of older adults with depression experienced their first episode at age 60 or later.

Mood Disorders: Etiology

• Late onset depression is characterized by vascular risk factors, lesions in the deep white matter of the brain, and executive functioning deficits.
• Early onset depression is associated with neuroticism.

Mood Disorders: Explanation for Age Differences

• Changes in frequency or impact of risk and protective factors over time may contribute to age differences in mood disorders.
• Biological risk factors increase with age, while psychological and social protective factors also increase.

Treatment and Assessment

• Depression is often under-detected in late life, and therapies include cognitive behavioral therapy, cognitive bibliotherapy, and problem-solving therapy.
• Internet-delivered cognitive behavioral therapy is equally effective in older adults as in younger and middle-aged individuals.

Suicide

• Older adults, particularly older men, have elevated rates of death by suicide.
• The rate of suicide in adults 65 years and older is 15.3, and 16.9 in adults 85 years and older.
• Suicidal acts and attempts in late life are exponentially more likely to be fatal than in younger adults.

Alcohol Use Disorders

• Alcohol use disorders are associated with severe mental and physical health consequences and increased risk of mortality.
• The prevalence of problematic alcohol use among older adults ranges from 1% to 22% in community populations.
• Excessive drinking declines with age, with the average amount consumed decreasing over time.

Personality Disorders

• Antisocial personality disorder and borderline personality disorder are less prevalent in older adults.
• Schizoid personality disorder and obsessive-compulsive personality disorder appear to be more prevalent.
• Older adults with antisocial personality disorder are more likely to endorse lying or deception than younger adults.

Sleep Disorders

• Sleep difficulties are common in older adults, with up to 34% reporting symptoms of insomnia.
• Sleep latency increases with age, becoming most pronounced after age 65.
• Total sleep time decreases by approximately 10 minutes for each decade of the life span.

Dementia

• The prevalence of dementia increases with age, with rates ranging from 1.5% in adults in their 60s to 15-25% in adults in their 80s.
• Dementia is more common among women than men.
• Life expectancy decreases with severity of dementia, especially for those 85 years and older.
• Alzheimer's disease accounts for approximately 60-70% of all dementia cases.