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A NEWSLETTER FOR PAIN PROFESSIONALS • SPRING/SUMMER, 2002
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Psychological Screening Offers Benefits for Chronically Ill Patients
The MBMD Test in Practice: The MBMD Test Helps Support Pre-surgical Psychological Evaluations
National Pain Awareness Week a Huge Success
Pain Management Resources
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New Billing Codes Available for Psychological Services with Medical Patients
Licensed healthcare professionals and psychologists have six new reimbursement codes available for billing for psychological services. These CPT (Current Procedural Terminology) codes can be used for psychosocial evaluations, reassessment and intervention of medical patients.
The American Psychological Association (APA) Practice Directorate recently issued an announcement and explanation of the codes to its membership. Please read the entire announcement, including estimated Medicare reimbursement rates, on the APA web site, www.apa.org. Click on "Programs & Offices" then on "Practice" then on "APA Practice Directorate Announces New Health and Behavior CPT Codes." For Frequently Asked Questions, please see www.apa.org/practice/cpt_faq.html.
Psychological Screening Offers Benefits for Chronically Ill Patients
By James R. Zabora, ScD
Note: This article is based on “Psychosocial Screening Among the Chronically Ill” by James R. Zabora, ScD. For a copy, call Kelly Robbins at 1-888-627-7271. He will be presenting at the Association of Oncology Social Work conference in May 2002.
What is the problem?
 hronic illnesses, such as cancer, renal disease, and AIDS, cause significant disruptions in the day-to-day lives of patients and families. Illness transforms persons into patients and simultaneously creates a series of challenges that must be addressed. While most patients learn to live with illness, a significant portion of patients struggle to make decisions, follow treatment regimens, and adhere to medication schedules.
Clearly, the early response to the diagnosis of a chronic or life-threatening illness varies significantly. Just as the distress varies, so do the psychosocial needs of each patient. While one patient may benefit primarily from education, another may benefit from a support group, and still another may need psychotherapy.1 The patterns of adaptation observed during the diagnostic phase often possess a history prior to the diagnosis. In many respects, patients respond to this crisis in a similar manner as they did to other difficult past events.
Each patient approaches the diagnosis and related treatments with a number of internal and external resources. Internal resources, including psychological status, level of optimism and spirituality, may influence how the patient begins to define his or her reaction to a chronic illness. The adequacy and availability of external resources, frequently labeled social support, also play a significant role. The greater the internal and external resources, the lower the patient’s distress, because these resources facilitate effective coping and problem-solving. Conversely, failure to problem-solve results in significant levels of emotional distress.
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| Continued, Psychological Screening Offers Benefits for Chronically Ill Patients |
Why should I screen for distress?
 Psychological screening can play a valuable part in the diagnostic process because patients who are experiencing distress often learn to conceal this factor from the health care team. Most patients perceive this covert activity as being appropriate since the health care team needs to focus their full attention on diagnosis and treatment. When a patient suppresses distress, it may become apparent to the team only when the distress has increased to the point at which the patient begins to lose control. Research indicates that patients with low internal and/or external resources may well experience a major crisis event two to six months after initial diagnosis.
Currently, most psychosocial care for patients with low resources is offered reactively; i.e., at the time of the crisis rather
than at diagnosis. Psychosocial screening offers unique opportunities to identify patients who may be at a higher risk early on and to link these patients with appropriate psychosocial interventions. Early interventions are less stigmatizing to the patient and more acceptable as part of comprehensive care. When distress is undetected and untreated, medical treatment outcomes are jeopardized, patient satisfaction decreases, and health care costs increase. Undetected psychological distress may be converted into multiple somatic complaints to which the health care team may respond by ordering unnecessary procedures, scans and medications.2
Why should I use the Brief Symptom Inventory 18 assessment as a screening instrument?
Screening for psychological distress requires the use of a standardized instrument that provides objective scores to define high-risk patient profiles.3 While a number of psychological instruments exist, the BSI® 18 (Brief Symptom Inventory 18) assessment, normed on an oncology and a community sample, offers a number of important benefits:
- In cancer populations, the 53-item BSI® test is the only standardized instrument that has been directly compared to the Omega Screening Instrument, the "gold standard" of psychosocial screening.4
- Test author Leonard R. Derogatis, PhD, has recently shortened the BSI instrument to contain just 18 items in the BSI 18 assessment, reducing patient time to 1–2 minutes. The shorter BSI 18 instrument offers the opportunity for early identification of vulnerable patients within the first medical visit, and enables psycho social providers to maximize re sources by targeting high-risk individuals. Clinical priorities can be established, and specific interventions offered for discrete psychological symptoms.
- The BSI 18 assessment provides three scale scores (Somatization, Depression, and Anxiety). Specific scores, such as the overall distress score or specific symptoms, such as anxiety, can help the clinician target specific interventions for the patient.
- The BSI 18 test creates a structure for outcomes measurement by enabling the clinician to track the patient’s distress through follow-up administrations of the instrument.
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How does managed care view psychosocial screening?
Over the past five years, managed care organizations have responded favorably to the use of psychological tests in screening patients with chronic illness because this approach:
- Helps the practitioner and the patient maximize internal and external psycho social resources and offers early intervention to lessen the potential of a psychological crisis, rather than intervention at the time of crisis when the patient is extremely anxious, depressed, or suicidal;
- Can help the practitioner decrease the patient’s distress while helping to increase patient satisfaction and quality of life;
- May reduce overall health costs by preventing exacerbation of pre-existing levels of distress and by decreasing somatic complaints to which the health care team might have responded by ordering unnecessary medications or procedures.
James R. Zabora, ScD, is Associate Director for Community Programs and Research at The Johns Hopkins Oncology Center in Baltimore and has authored numerous articles on the psychosocial care of cancer survivors and their families. He is the co-editor of the Journal of Psychosocial Oncology and a former president of the Association of Oncology Social Work, receiving the Association’s National Leadership Award in 1994.
End Notes
1 James Zabora, Matthew Loscalzo. Comprehensive Psychosocial Programs: A Prospective Model of Care. Oncology Issues, 11(1), 1996, 14-18.
2 James R. Zabora, Matthew Loscalzo, Elizabeth D. Smith. "Psychosocial Rehabilitation" in Clinical Oncology, Abeloff, M.D., Armitage, J.O., Lichter, A.S., Niederhuber, J.E. (Eds.). New York: Churchill Livingstone, 2000.
3 James R. Zabora. "Pragmatic Approaches in the Psychosocial Screening of Cancer Patients and Their Families" in Handbook of Psychooncology, 2nd Ed., Holland, J., Breibart, P., & Loscalzo, M. (Eds.). London: Oxford Press, 1998.
4 James R. Zabora, Rebecca Smith-Wilson, John H. Fetting, John P. Enterline. An Efficient Method for the Psychosocial Screening of Cancer Patients. Psychosomatics, Vol. 31(1), 1990, 192-196.
Additional Resource
Leonard R. Derogatis. The Brief Symptom Inventory (BSI): Administration, Scoring and Procedures Manual (3rd Ed.). Minneapolis, MN: NCS Pearson, Inc., 1993.
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| THE MBMD™ TEST IN PRACTICE
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Following is the second in a series of articles to inform readers on the use of the MBMD test in different medical settings. The previous issue illustrated the role of the MBMD test in evaluating organ transplant candidates. The article below discusses the assessment’s role with pre-surgical psychological evaluations of candidates for implantable pain management devices. Future articles will focus on such areas as bariatrics, HIV and diabetes.
The MBMD Test Helps Support Pre-surgical Psychological Evaluations
Marilyn S. Jacobs, PhD, a clinical psychologist, conducts pre-surgical psychological evaluations of patients who are candidates for implantable devices used to help manage pain. These patients are referred by physicians who treat pain and recognize the psychological evaluation as an essential step in helping to maintain quality of care. Jacobs includes psychological testing within her evaluation protocol. This testing helps provide her with objective, scientifically-sound data that she adds to the information gained from the patient interview. Overall, the goal of her evaluation is to help determine if a patient is a good candidate for this type of medical intervention.
Preparation helps improve patient compliance
Jacobs first reviews the patient’s medical and mental health records to become familiar with the context of the patient’s pain. She then telephones the patient to explain the reason for the evaluation, describe the procedure, discuss the patient’s past experience with mental health care (if any), and make herself available for questions. Jacobs has found that the pre-appointment phone call helps decrease patient anxiety about the psychological screening and helps increase the success rate of the evaluation itself.
Screening protocol targets need for further testing
During the first office visit the patient completes brief psychological assessments that help screen for anxiety, depression and general adaptation to illness. This initial information enables Jacobs to review with the patient at their first meeting any significant results the tests may reveal.
A two-hour clinical interview follows, after which Jacobs decides if a psychodiagnostic assessment is needed. For the psychodiagnostic assessment, Jacobs administers the MBMD™ (Millon™ Behavioral Medicine Diagnostic) assessment along with the MCMI-III™ (Millon™ Clinical Multiaxial Inventory-III) test. In the more complicated cases, she also may administer the MMPI-2™ (Minnesota Multiphasic Personality Inventory-2™) test and SCL-90-R® (Symptom Checklist-90-Revised) assessment. In legal cases requiring an assessment of potential malingering, she uses the VIP® (Validity Indicator Profile) assessment.
The MBMD test helps support an objective evaluation
Jacobs uses the MBMD test to help determine the existence and degree of personality disorders and negative health habits, such as eating disorders, inactivity, smoking, alcohol or chemical dependency. Additionally, she looks for the patient’s test-taking attitude, any highly abnormal validity scales, how the patient is coping with the medical condition, and if the patient is exaggerating symptoms. She also wants to know if the patient regards the implant device as a "magic bullet" or, preferably, has a realistic appraisal of the benefits the device can actually provide.
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The scales in the MBMD test’s Treatment Prognostics domain—Interventional Fragility, Medication Abuse, Information Discomfort, Utilization Excess, and Problematic Compliance—provide the most valuable information to Jacobs, "because we’re talking about a very complicated procedure that really requires the patient to be cooperative and work with the physician."
"The MBMD assessment is an excellent and relevant tool to get the information I need from medically ill pain patients in a very cost-effective way."
"The Interventional Fragility scale on the MBMD [test] is a particularly useful and relevant scale," she explains, "because it shows if someone is likely to have a problem with the procedure. The Interventional Fragility vs. Interventional Resilience scale helps measure fear related to medical procedures and will help predict if a patient will be able to adjust emotionally to this type of stress. The information gained from this scale helps the psychologist prepare a patient for procedures, which in turn will help to ensure a good outcome."
MBMD results compare test taker to other medical patients
The MBMD assessment was normed on medical patients in a wide range of treatment settings, a feature Jacobs finds especially helpful. "I’m comparing my patients to a population of like people," Jacobs explains. "This enables me to be more scientific with results from the MBMD test."
"This test is as effective as it is," she continues, "because it is normed on medical patients, so the scores have taken that into consideration." Dr. Jacobs summarizes her experience with the MBMD test by saying, "The MBMD assessment is an excellent and relevant tool to get the information I need from medically ill pain patients in a very cost-effective way."
Marilyn S. Jacobs, PhD, ABPP, practices psychology in Westwood, California. She earned her PhD in clinical psychology, a PsyD in psychoanalysis, and is a diplomate in psychoanalysis with the American Psychological Association. She is also a licensed physicians’ assistant and works primarily with people who have chronic pain, using a psychoanalytic perspective. In addition, she teaches pain fellows in Anesthesiology at the University of California, Los Angeles and recently co-authored an article about screening patients for implantable devices, published in the Clinical Journal of Pain.
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| NATIONAL PAIN AWARENESS WEEK A HUGE SUCCESS
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The First National Pain Awareness Week kicked off in conjunction with the annual American Academy of Pain Medicine (AAPM) conference February 26-March 3, 2002. "National Pain Awareness Week was a huge success," says Mary Pat Aardrup, Director of the National Pain Foundation (NPF). "We doubled the number of registered users on www.NationalPainFoundation.org and have seen a 100% increase in user sessions."
Important educational information written for the public can be found on the NPF’s web site www.NationalPainFoundation.org. Aardrup reports that, as a result of publicity gained through the National Pain Awareness Week, material from the NPF was picked up by the online publication "Health Source" and subsequently by Yahoo. These sources were a major factor in leading people to the www.NationalPainFoundation.org web site.
National Pain Awareness Week is a joint effort of the National Pain Foundation and American Academy of Pain Medicine to promote public awareness of the resources available to chronic pain patients. The event will be repeated yearly in conjunction with the AAPM Annual meeting.
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| PAIN MANAGEMENT RESOURCES
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Tradeshows
Visit with us! Be sure to stop by our booth at these upcoming conferences:
Association of Oncology Social Work (AOSW)
May 4–7, 2002
Atlanta, GA
Presentation: Critical Clinical Concepts in the Management of Distress Among Cancer Patients,
James R. Zabora, MSW and Linda Diaz, MSW
www.aosw.org
Multidisciplinary Pain Medicine Update
May 24–26, 2002
Orlando, FL
www.neuromodulation.org
American Headache Society (AHS)
June 21–23, 2002
Seattle, WA
www.ahsnet.org
American Society for Bariatric Surgery (ASBS)
June 24–28, 2002
Las Vegas, NV
www.asbs.org
International Association for the Study of Pain® (IASP®)
August 17–22, 2002
San Diego, CA
www.iasp-pain.org
Visit Our Website!
http://www.pearsonassessments.com/medical/index.htm
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Additional Websites
American Academy of Disability Evaluating Physicians (AADEP)
www.aadep.org
American Academy of Neurology (AAN)
www.aan.com
American Academy of Pain Management (AAPM)
www.aapainmanage.org
American Academy of Pain Medicine (AAPM)
www.painmed.org
American Pain Society (APS)
www.ampainsoc.org
American Society of Interventional Pain Physicians (ASIPP)
www.asipp.org
American Society of Regional Anesthesia & Pain Medicine (ASRA)
www.asra.com
Health Psychology and Rehabilitation
www.healthpsych.com
International Spinal Injection Society (ISIS)
www.spinalinjection.com
Joint Commission on Accreditation of Healthcare Organizations (JCAHO)
www.jcaho.org
The National Pain Foundation (NPF)
www.NationalPainFoundation.org
Society for Pain Practice Management (SPPM)
www.sppm.org
Society of Behavioral Medicine (SBM)
www.sbmweb.org
www.pain.com |
Learn More about Psychological Testing
Please contact us at 1-888-627-7271 for more information about testing and additional resources.
To request a print copy of this newsletter, please call 1-888-627-7271 and reference F12SPSU02.
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