Capacity Evaluation Requests in the Medical Setting: A Retrospective Analysis of Underlying Psychosocial and Ethical Factors.

BACKGROUND: Psychosocial and ethical variables influence physicians in requesting decision-making capacity (DMC) evaluations. Previous authors have classified certain DMC evaluation requests as "unwarranted" when there is no explicit suspicion or evidence that the patient might lack DMC. OBJECTIVE: To explore psychosocial and ethical reasons motivating both "warranted" and "unwarranted" DMC evaluation requests by physicians in the medical setting. METHODS: A retrospective electronic health record review was approved by the institutional review board. All psychiatric consultation requests identified as DMC evaluation requests between January 1, 2012 and December 31, 2012 were assessed independently by 2 reviewers. Each reviewer identified each DMC evaluation request as "warranted" vs "unwarranted." Unwarranted DMC evaluation requests were defined as those lacking explicit suspicion that the patient might lack DMC or those with explicit evidence of a patient with blatantly impaired DMC. We hypothesized that most (over half) DMC evaluation requests would be deemed unwarranted. Descriptive statistics, chi-square/Fisher exact tests, and t-test/ANOVA were used. RESULTS: A total of 146 DMC evaluations were reviewed, and 83 (56.8%) of these were deemed unwarranted. Of these, most were likely driven by a previous neuropsychiatric disturbance (p < 0.001). Various other psychosocial and ethical patterns were identified (i.e., the practice of defensive medicine and guardianship concerns). CONCLUSION: Over half of DMC evaluation requests in a general medical setting were unwarranted. Many such requests were motivated by unarticulated psychosocial and ethical factors. DMC evaluation requests appear to serve as a means for indirectly resolving various psychosocial and ethical dilemmas beyond assessing DMC itself. Implications and future directions are discussed.

Do demographic factors influence detection of invalid neuropsychological test performance using common performance validity tests? A multisite investigation.

OBJECTIVE: This study examined the extent to which demographic variables (i.e., age, education, premorbid IQ, sex, ethnoracial identity, and presence/absence of external incentive) affect performance validity test (PVT) performance. METHOD: This cross-sectional study examined two distinct, diverse outpatient clinical samples at an academic medical center (AMC, N = 268) and a Veterans Affairs (VA) medical center (N = 111). All patients completed a battery including five PVTs. Premorbid IQ was assessed using the Test of Premorbid Functioning (TOPF) in the AMC sample. RESULTS: Multiple correlations between demographic variables and individual PVT performance were statistically significant, but accompanying effect sizes were small, except for the relationship of premorbid IQ and reliable digit span (RDS). Regressions showed demographic variables accounted for 7%-11% of the variance in individual PVT scores in the AMC sample, and 6%-26% in the VA sample, premorbid IQ driving results in the AMC sample and compensation-seeking status in the VA sample. Other demographic variables did not correlate with compensation-seeking status. Additionally, premorbid IQ was found to be significantly higher in validly performing individuals compared to those performing invalidly in the AMC sample. CONCLUSION: Most demographic factors evaluated accounted for relatively little variance in individual PVT performance and did not significantly predict overall validity categorization. Compensation-seeking status correlated with validity classification across both groups, but offers limited diagnostic utility itself compared to objective PVT scores. Premorbid IQ within the AMC group demonstrated influence on particular PVTs (i.e., RDS) reflecting the difficulty of assessing validity within low IQ populations, particularly with PVTs more strongly correlated with IQ. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Comprehensive Analysis of MMPI-2-RF Symptom Validity Scales and Performance Validity Test Relationships in a Diverse Mixed Neuropsychiatric Setting.

The utility of symptom (SVT) and performance (PVT) validity tests has been independently established in neuropsychological evaluations, yet research on the relationship between these two types of validity indices is limited to circumscribed populations and measures. This study examined the relationship between SVTs on the Minnesota Multiphasic Personality Inventory-2-Restructured Form (MMPI-2-RF) and PVTs in a mixed neuropsychiatric setting. This cross-sectional study included data from 181 diagnostically and demographically diverse patients with neuropsychiatric conditions referred for outpatient clinical neuropsychological evaluation at an academic medical center. All patients were administered a uniform neuropsychological battery, including the MMPI-2-RF and five PVTs (i.e., Dot Counting Test; Medical Symptom Validity Test; Reliable Digit Span; Test of Memory Malingering-Trial 1; Word Choice Test). Nonsignificant associations emerged between SVT and PVT performance. Although the Response Bias Scale was most predictive of PVT performance, MMPI-2-RF SVTs generally had low classification accuracy for predicting PVT performance. Neuropsychological test performance was related to MMPI-2-RF SVT status only when overreporting elevations were at extreme scores. The current study further supports that SVTs and PVTs measure unique and dissociable constructs among diverse patients with neuropsychiatric conditions, consistent with literature from other clinical contexts. Therefore, objective evidence of symptom overreporting on MMPI-2-RF SVTs cannot be interpreted as definitively indicating invalid performance on tests of neurocognitive abilities. As such, clinicians should include both SVTs and PVTs as part of a comprehensive neuropsychological evaluation as they provide unique information regarding performance and symptom validity.