Quality of Neuropsychological Assessment: Effect of Feedback on Neuropsychological Performance and Treatment-outcome

A significant minority of patients does not give an accurate or truthful
account of their symptoms and cognitive capacities. Various reasons for this
behavior are described in the literature, such as unwillingness to cooperate
with the assessment due to external gain (e.g., financial benefits), or due to
psychological disorders (e.g., urge to play a patient role) (Carone, Iverson &
Bush, 2010). Invalid symptom reporting may lead to false diagnosis and,
consequently, inadequate treatment. An invalid presentation of symptoms and
cognitive capacities can be measured using specialized symptom validity tests
(SVTs). There are two kinds of SVTs; (a) measures for invalid symptom
reporting, and (b) measures for determining invalid performance on
neuropsychological tests (i.e., underperformance) (Dandachi-FitzGerald, et al.,
2011). Although progression is made in diagnosing underperformance during
neuropsychological assessment, little is known about how to deal with invalid
performance in the clinical setting. To our knowledge, Suchy et al. (2012) were
the first to examine whether providing feedback to patients who failed an SVT
had an impact on subsequent test performance. They found that two thirds of
Multiple Sclerosis patients who were presented with feedback about their
underperformance showed significant improvement in both repeated SVT
performance, but also on subsequent memory testing. This study had several
limitations. First, assignment between feedback- and no-feedback groups was not
randomized. Second, the SVT was only repeated in case the patient scored below
the cut-off. Therefore, the potential test-retest effect on re-administration
of the SVT remains uncertain. Furthermore, although psychometric properties of
SVTs is extensively studied and documented, currently very little is known
about the relationship between SVT failure and treatment-outcome in health
care. Horner, vanKirk, Dismuke, Turner and Muzzy (2014), are the first to study
the relationship between SVT failure and healthcare utilization. They found
that SVT failure is associated with higher healthcare utilization, compared to
patients passing an SVT. Goedendorp et al. (2013), found that patients with
chronic fatigue syndrome (CFS) showing underperformance during
neuropsychological assessment, did drop out of the cognitive behavioral
treatment more often compared to patients who were not underperforming. On a
related note, Van Egmond, et al. (2002; 2005) found that psychiatric patients,
who expected external gains from being in treatment, benefited less from their
treatment than those patients that did not have these expectations. In line
with these finding, Sharpe et al. (2009) found that health-related financial
benefits predict poor treatment outcome in neurology outpatients with symptoms
unexplained by disease. To summarize, although the body of evidence is limited,
these results suggest that underperformance and external gain have a potential
negative influence on treatment-outcome.

To examine whether providing feedback to patients immediately after scoring in
a non-valid range on a SVT would have an impact on subsequent symptom validity
and neuropsychological test performance. Furthermore, we examine
treatment-outcome as a result of external gain and underperformance.

Randomized single-blind controlled trial (RCT)

In case the patient passed the ASTM, the following feedback is provided:

No feedback on performance (FB-). Verbatim, in Dutch:
* In het kader van het onderzoek zal ik enkele testen die ik zojuist bij u heb
afgenomen herhalen*.

In case of ASTM failure, the technician uses a concealed envelope to offer the
patient the allocated regimen (i.e., FB+ or FB-):

Specific feedback on performance (FB+). Verbatim, in Dutch:
* In het eerste deel van het onderzoek presteerde u lager dan verwacht. Daarom
zal ik enkele testen die ik zojuist bij u heb afgenomen herhalen*.

No feedback on performance (FB-). Verbatim, in Dutch:
*In het kader van het onderzoek zal ik enkele testen die ik zojuist bij u heb
afgenomen herhalen*.

Patients referred for neuropsychological assessment will be included. Most of
the measures used in this study are among the standard neuropsychological test
used in the clinic. After randomization, the technician will provide feedback
on the ASTM performance (see also the flow chart of the study procedure, p.16).
This will take about 2 minutes. It is common for the technician to optimize the
assessment conditions (e.g., motivate the patient, make sure no distracting
external influences are present, etc.). It is our experience that motivating
the patient (i.e., providing feedback on test performance during the
assessment) is not perceived as stressful by the patient. After the technician
provided the feedback, the first tests are repeated and the neuropsychological
examination is continued: In case of ASTM failure, all three tests (ASTM, digit
span and word fluency) are repeated. In case the patient passed the ASTM, digit
span and word fluency are repeated. The Short Form Health-Survey (SF-36) and
iMTA Medical Consumption Questionnaire (iMCQ) will be administered two times:
the first time during the neuropsychological assessment and a second time after
three months, during which these two questionnaires are sent to the patients by
e-mail. The patiënts can also fill out these questionnaires by paper-pencil
upon request. There will be no direct benefit for the participants.