Forensic Mental Health Assessment as a Critical Intercept for Enhancing Mental Health Care.

Rates of psychiatric diagnosis, medical morbidity, and suicide risk are notably high among incarcerated individuals. However, engaging these individuals in community-based health care settings can be a challenge. Among justice-involved individuals who do access services, community-based health care settings may lack available resources to effectively conduct comprehensive assessments that inform evidence-based conceptualization. We propose forensic mental health assessment (FMHA) as a critical opportunity to enhance service delivery for this at-risk population. In particular, within the scope of their role, forensic mental health evaluators are able to conduct a comprehensive review of records across health (eg, inpatient and outpatient health care settings), social (eg, homeless shelter), and correctional (eg, jail or prison) settings. Moreover, FMHA often includes specialized batteries that are able to assess and differentially diagnose myriad clinical presentations that may have overlapping symptomatology. We present 2 case vignettes to illustrate the utility of FMHA for enhancing service delivery. Finally, we conclude by noting challenges to integrating FMHA into conceptualization and necessary next steps in research and programing.

Parent ratings of executive functioning in pediatric survivors of medulloblastoma and pilocytic astrocytoma.

The present study compared parent-rated executive functioning in pediatric medulloblastoma (MB) and pilocytic astrocytoma (PA) survivors. Although standard care for both includes surgical resection, children with MB additionally receive chemotherapy and craniospinal irradiation. Given well-documented neurocognitive late effects associated with the latter, we anticipated poor parent-reported executive functioning in MB survivors. Parents/guardians of 36 MB survivors and 20 PA survivors completed the Behavior Rating Inventory of Executive Functioning (BRIEF). PA survivors were younger at diagnosis (t[51.97] = 3.07, p < .001, d = 0.86) and demonstrated higher IQ (t[54] = -3.51, p < .001, d = 0.95). However, relative to the MB group, the PA group was rated as having significantly more problems on all BRIEF scales (all p ≤ .05; d = 0.30 - 1.10), except the Shift scale. Additionally, all mean BRIEF scores for MB survivors were within normal limits, whereas for PA survivors, all mean BRIEF scores except for Organization of Materials were significantly discrepant from normative means. Overall, PA survivors were rated as demonstrating poorer executive function than MB survivors. Five theories are discussed as possible explanations for these surprising findings: two related to group differences, two related to potential sources of parental bias, and one related to the nature of questionnaire-based assessment. All these theories represent directions for future research. Parent questionnaires such as the BRIEF may have real-world implications for pediatric brain tumor survivors. Future research should explore factors affecting parent ratings of executive functioning in these populations, along with comparison to performance-based measures.

Auditory attention late effects in pediatric acute lymphoblastic leukemia.

This study sought to characterize auditory attention functioning among pediatric Acute Lymphoblastic Leukemia (ALL) survivors treated on a chemotherapy-only protocol, given previous literature suggesting late impact on sustained visual attention. We hypothesized similar deficits would be observed in auditory attention relative to previous literature indicating weakness with aspect of visual attention in this population. Survivors (n = 107, 53 females, M = 12.80 years) completed the Conners Continuous Auditory Test of Attention (CATA). Parents completed the Behavior Assessment System for Children, Second Edition and reported educational performance and services via structured questionnaire. Results indicated several CATA indices associated with sustained auditory attention were significantly worse than normative data, though group means were average. Reflecting individual variability in performance, 50% of the sample performed worse than one standard deviation from the mean on at least one CATA variable. Parent report of attention did not differ from normative means for the sample. Parent-report data indicated that 60% of the sample utilized academic support services, with a large proportion of survivors having utilized special education services. Poorer performance with sustained auditory attention was associated with poor academic outcomes. Greater methotrexate exposure and younger age at diagnosis were risk factors for inattentiveness. No gender differences were identified on direct assessment of auditory attention or parent report of attention, though male gender was associated with poorer educational performance. Findings suggest that auditory attention is an at-risk cognitive domain following treatment for pediatric ALL, and that an association exists between auditory attention and school performance in this population.

Consistency of traumatic brain injury reporting in older adults with and without cognitive impairment.

OBJECTIVE: Medical history information regarding prior traumatic brain injury (TBI) usually relies on self-report, although little is known about the reliability of this information with regard to injuries sustained years or decades earlier. Even less is known about the reliability of self-reported medical history information in older individuals with cognitive impairment. To this end, we assessed the test-retest reliability of self-reported TBI history in a large, national sample. METHODS: Participants (n = 4309) were older adults with intact cognition, mild cognitive impairment (MCI) and Alzheimer's disease (AD) from the National Alzheimer's Coordinating Center. Subjects provided TBI history information at baseline and one annual follow-up visit. Consistency of self-reported history of TBI with <5 minutes loss of consciousness (mLOC) and TBI with ≥5 mLOC reported at time 1 and 2 was analyzed across diagnostic groups. RESULTS: Overall, subjects provided reports of TBI history at follow-up that were highly consistent with baseline reports (97.8-99.6% agreement), and Cohen's kappa coefficients were all larger than .80 and statistically significant, maximum p < .001. Furthermore, level of cognitive impairment was not a significant predictor of consistency in reporting. CONCLUSIONS: These data are some of the first to suggest that self-report may be a consistent method of obtaining remote TBI history in the absence of medical records for older individuals, regardless of cognitive impairment.

Predictors That a Diagnosis of Mild Cognitive Impairment Will Remain Stable 3 Years Later.

BACKGROUND AND OBJECTIVE: In half to two thirds of patients who are diagnosed with mild cognitive impairment (MCI), the diagnosis neither converts to dementia nor reverts to normal cognition; however, little is known about predictors of MCI stability. Our study aimed to identify those predictors. METHODS: We obtained 3-year longitudinal data from the National Alzheimer's Coordinating Center Uniform Data Set for patients with a baseline diagnosis of MCI. To predict MCI stability, we used the patients' baseline data to conduct three logistic regression models: demographics, global function, and neuropsychological performance. RESULTS: Our final sample had 1059 patients. At the end of 3 years, 596 still had MCI and 463 had converted to dementia. The most reliable predictors of stable MCI were higher baseline scores on delayed recall, processing speed, and global function; younger age; and absence of apolipoprotein E4 alleles. CONCLUSIONS: Not all patients with MCI progress to dementia. Of the protective factors that we identified from demographic, functional, and cognitive data, the absence of apolipoprotein E4 alleles best predicted MCI stability. Our predictors may help clinicians better evaluate and treat patients, and may help researchers recruit more homogeneous samples for clinical trials.

Borderline Personality Disorder and Military Sexual Trauma: Analysis of Previous Traumatization and Current Psychiatric Presentation.

Military sexual trauma (MST) increases vulnerability for posttraumatic stress disorder (PTSD). Sexual trauma is also associated with increased risk for developing borderline personality disorder (BPD). Research has also documented a significant link between PTSD and BPD; however, there is a paucity of information examining this relationship among veterans with MST-related PTSD. In particular, we sought to examine whether comorbid BPD-PTSD compared with veterans with PTSD and no BPD resulted in increased PTSD and depression symptomatology. We also examined psychiatric, previous sexual trauma, and demographic factors to determine what-if any-factors were associated with comorbid BPD diagnosis. Using data from a recently conducted randomized clinical trial, we examined electronic medical records of the local Veterans Affairs Medical Center. Data from 90 veterans with MST-related PTSD were obtained. More than 22% ( n = 20) of the sample had a historical diagnosis of BPD. Participants were administered measures to assess psychiatric symptomatology (PTSD and depression), trauma-related negative cognitions (NCs), and previous sexual traumatization (e.g., childhood and civilian sexual exposure). An analysis of variance was conducted, which found that veterans with comorbid MST-related PTSD and BPD had significantly greater PTSD criterion B (avoidance) symptoms, depressive symptomatology, and NC scores than participants without comorbid BPD. In addition, a binary stepwise logistic regression found that veterans' BPD was also positively associated with NCs about self and the world; however, self-blame, depression, PTSD, sociodemographic variables (e.g., gender, age), and previous sexual traumatizations were not significant predictors. Implications are discussed with regard to clinical care and future research directions.

Traumatic brain injury history is associated with earlier age of onset of Alzheimer disease.

OBJECTIVE: This study examined whether a history of traumatic brain injury (TBI) is associated with earlier onset of Alzheimer disease (AD), independent of apolipoprotein ε4 status (Apoe4) and gender. METHOD: Participants with a clinical diagnosis of AD (n = 7625) were obtained from the National Alzheimer's Coordinating Center Uniform Data Set, and categorized based on self-reported lifetime TBI with loss of consciousness (LOC) (TBI+ vs. TBI-) and presence of Apoe4. ANCOVAs, controlling for gender, race, and education were used to examine the association between history of TBI, presence of Apoe4, and an interaction of both risk factors on estimated age of AD onset. RESULTS: Estimated AD onset differed by TBI history and Apoe4 independently (p's < .001). The TBI+ group had a mean age of onset 2.5 years earlier than the TBI- group. Likewise, Apoe4 carriers had a mean age of onset 2.3 years earlier than non-carriers. While the interaction was non-significant (p = .34), participants having both a history of TBI and Apoe4 had the earliest mean age of onset compared to those with a TBI history or Apoe4 alone (MDifference = 2.8 and 2.7 years, respectively). These results remained unchanged when stratified by gender. CONCLUSIONS: History of self-reported TBI can be associated with an earlier onset of AD-related cognitive decline, regardless of Apoe4 status and gender. TBI may be related to an underlying neurodegenerative process in AD, but the implications of age at time of injury, severity, and repetitive injuries remain unclear.

Does mild cognitive impairment always lead to dementia? A review.

Mild cognitive impairment (MCI) has often been studied in its association with dementia, yet higher rates of reversion to normal cognition than progression to dementia suggest that MCI does not necessarily lead to dementia. Compared to the numerous studies on MCI progression, relatively few have examined reversion. This paper highlights the current literature on characteristics and predictive factors of MCI reversion, along with an overview of studies on MCI patients who remain diagnostically stable (i.e., MCI stability). Of the available studies, predictors of reversion have been noted in areas of cognitive/global functioning, demographic/genetic/biomarker data, and personality/lifestyle factors. However, there is a need for increased study of MCI reversion, considering that patients in this group can fluctuate between different trajectories of MCI (e.g., normal cognition back to MCI or even progression to dementia) within a given follow-up time period. Further examination of reversion via a longitudinal, multifactorial approach would better inform clinicians regarding the likelihood of reversion amongst MCI patients and subsequently modify treatment methods accordingly. Furthermore, researchers would have greater power in detecting treatment effects in their clinical intervention studies of early dementia by improving selection criteria to exclude MCI participants who are more likely to revert and remain cognitively normal than progress to a dementia.

Psychometric validation of the 16 Item Quick Inventory of Depressive Symptomatology Self-Report Version (QIDS-SR16) in military veterans with PTSD.

BACKGROUND: The Quick Inventory of Depressive Symptomatology-Self Report (QIDS-SR16) is one example of a screening tool for depression, which has been utilized extensively following validation in a number of clinical populations. Despite the strengths of the QIDS-SR16, it has not been validated in military veterans, a particularly unique population considering their exposure to trauma and high rate of psychiatric comorbidities. The current report describes a psychometric validation of the QIDS-SR16 in a sample of United States military veterans diagnosed with military-related PTSD. METHODS: Participants (n=240) were administered the QIDS-SR16 and one of two gold-standard semi-structured interviews to establish diagnosis of a current Major Depressive Episode (MDE). The ability to discriminate between individuals with and without a current MDE using the QIDS-SR16 was tested with a stepwise logistic regression. Additionally, an optimal cutoff score for the QIDS-SR16 was established. RESULTS: The QIDS-SR16 was able to reliabily discriminate between individuals with and without a current MDE. The optimal cutoff score of the QIDS-SR16 for a current MDE was 13, with a sensitivity of 77.55% and specificity of 56.25%. LIMITATIONS: Limitations of this study included underrepresentation of some racial/ethnic groups, the inability to disentangle the potential influence of trauma type and gender on results, and the use of two diagnostic interviews to diagnose current MDE. DISCUSSION: The QIDS-SR16 can be effectively utilized in military veterans with comorbid PTSD. However, the calculated cutoff score for this population was higher than the cutoff score for the general population. This could result from the overlap between PTSD and MDE symptoms.