Medical care and psychological testing
My sister is a baccalaureate nurse. She worked in a few hospitals in the province of Québec in the past years and she is now working in the intensive care ward of a hospital in Ontario. I was curious to learn more about the role of psychological assessments in the medical domain. Medical practices of the bio-medical model have been segregated into two types of care a long time ago; physical treatment and psychological treatment. The gap caused by this dualism is slowly shrinking since we came to know more about both phenomenons and to understand their intricate interactions, but there is still a lot of work left to do.
I asked her about the services, protocols and tools used for the assessment of psychological distress/pain experienced by the patients she is working with.
Chiefly, I want to emphasize that patients which stay in the critical care unit are largely, as the name implies, in a physical state that requires immediate care in order to have their lives saved. It is not an optimal moment to assess psychological constructs (the main objective is to stabilize the patient, make sure that the body is fine before turning to their psychological state) but as my sister pointed, there is a large proportion of patients who come in for a physical symptom and show mental health issues and needs. Also, a stay in the hospital and the state of suffering is extremely anxiety-provoking for many people, it is often difficult to know the cause(s) of the symptom(s) experienced. The biopsychosocial approach is getting more common in hospital settings, it is not only used in alternative medicine anymore.
If patients want a psychological consultation, they usually have to ask for it and they then meet with a psychiatrist and/or a specialized mental health nurse for an interview. They probably use different testing tools and assessment methods (i.e. neuropsychological tests), but I will focus on those used by regular nurses on a day-to-day basis.
I will briefly address the tools commonly used by nurses to test delirium, depression and anxiety, suicidal emergencies and I will end by talking about a cognitive screening test.
Delirium
The test used to identify and recognize a delirium state is the Confusion Assessment Method (CAM). It assesses disorientation, memory impairment, psychomotor agitation, psychomotor retardation, and sleep disturbances. A short version of it exists, which takes about 5 minutes to fill. Even though it has significantly less items, it has been shown to be a reliable test to distinguish delirium from the other possible cognitive impairments.
It is therefore a test that is quick to learn, easy to administer, realistic considering the amount of time nurses have per patient during a working shift and it is also concretely useful.
Depression (DSM IV)
Depressive symptoms can be observed, in a hospital setting, by using tests such as the Patient Health Questionnaire (PHQ-9) or the Beck Depression Inventory® — Second Edition (BDI-II). Both use the DSM IV diagnosis criteria as a basis and are reliable as well as valid methods to assess the presence of depression and the need for intervention. The first test comprises only 9 items, is approximately 3 minutes long and provides the medical staff with a score that falls into one of 5 categories: minimal, mild, moderate, moderately severe and severe depression. The BDI takes about 5 minutes to fill, comprises 21 items and the scores are categorized into minimal, mild, moderate or severe depressive state.
Behaviors that could motivate such test taking would typically be:
- a change in affect
- a change in usual sleeping or eating patterns
- a disorganization of cognition (i.e. confused speech)
- atypical eye contact, posture and actions
Anxiety
Anxiety is assessed by nurses many times a day in a very similar way as for physical pain . Patients are asked to rate their anxiety on a scale from 1(no anxiety) to 10 (extreme anxiety). More tests can be performed when needed, and this would usually be taken in charge by specialized nurses, psychiatrists or doctors.
Suicidal emergencies
In cases where the patient is at risk of making a suicide attempt, nurses will engage in their helping alliance by asking questions. The most important questions, when the patient verbalizes his/her intention to commit suicide is to assess their (in french) COQ: Comment, où, quand (How, where, when) the patient think of executing his plan. The more the patient’s COQ is clear, the greater the emergency is. From there, the medical team establish a plan and the patient stays in close observation until further action is taken.
The signals that may indicate a suicidal risk are:
- The same signals as those mentioned for depression
- Heredity
- Family situation and support network
As you can see, in those cases nurses have to be self-reliant in their evaluation, ask the questions they see fit in the situation and report the information they get from the patient so that the risks may be minimized.
Cognitive screening
Last but not least, I want to talk about a test that is used by many professionals in the medical domain: the clock-drawing test.
The instructions are simple; Draw a clock on a plain sheet of white paper, and put the hands at a specific time (11:10). This test serves to evaluate the patient’s cognitive functions, it is therefore useful in the assessment of Alzheimer Disease progress. The criteria that are addressed are the executive functioning, the cognitive status in general, the visuospatial abilities, attention and semantic knowledge.
In conclusion, what I wanted to draw upon for this blog post is the importance of integrative medicine practices that are holistic, treating the mind and the body conjointly. It makes a difference by enhancing the diagnosis that is beneath the felt pain, and has been shown to “predict the transition from acute to chronic status” because there is many mechanisms that can impact the amount of pain that is perceptually experienced by patients (especially chronic pain). As my sister pointed to me, most of the perceived/reported psychological suffering is rapidly treated with anti-depressants, and many conditions such as chronic pain create a vicious cycle: suffering constantly makes you feel depressed, feeling depressed increases the pain felt, and so forth.
I believe that a biopsychosocial approach maximizes the possible outcomes of an hospital stay. Patients see a lot of nurses and medical staff during their stay(s), unfortunately a bond of trust cannot always be established and this makes it difficult to integrate mental health concerns on equal terms with the body. Still, patients can be empowered and supported when the necessary means and tools are given to those who provide medical care.
I also believe that there is always place for amelioration and I strongly think that it is relevant to assess psychological factors at all times in the field of medicine. Hence the importance of psychological test development and validation.
Claudia Gemme
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“Biomedical knowledge is essential for providing sound medical care, but it is not sufficient. The nature of dysfunctions and the physicians’ transaction with the patient must also be informed by the psychosocial understanding.”
Saeed H. Wahass, PhD, CPsychol., AFBPsS
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