Answers to 7 questions about using neuropsychological testing in your practice

Neuropsychological evaluation, consisting of a thorough examination of cognitive and behavioral functioning, can make an invaluable contribution to the care of psychiatric patients. Through the vehicle of standardized measures of abilities, patients’ cognitive strengths and weaknesses can be elucidated—revealing potential areas for further interventions or to explain impediments to treatment. A licensed clinical psychologist provides this service.

You, as a consumer of reported findings, can use the results to inform your diagnosis and treatment plan. Recommendations from the neuropsychologist often address dispositional planning, cognitive intervention, psychiatric intervention, and work and school accommodations.


Probing the brain−behavior relationship

Neuropsychology is a subspecialty of clinical psychology that is focused on understanding the brain–behavior relationship. Drawing information from multiple disciplines, including psychiatry and neurology, neuropsychology seeks to uncover the cognitive, behavioral, and emotional difficulties that can result from known or suspected brain dysfunction. Increasingly, to protect the public and referral sources, clinical psychologists who perform neuropsychological testing demonstrate their competence through board certification (eg, the American Board of Clinical Neuropsychology).

How is testing conducted? Evaluations comprise measures that are standardized, scored objectively, and have established psychometric properties. Testing can performed on an outpatient or inpatient basis; the duration of testing depends on the question for which the referring practitioner seeks an answer.

Measures typically are administered by paper and pencil, although computer-based
assessments are increasingly being employed. Because of the influence of demographic variables (age, sex, years of education, race), scores are compared with normative samples that resemble those of the patient’s background as closely as possible.

A thorough clinical interview with the patient, a collateral interview with caregivers
and family, and review of relevant medical records are crucial parts of the assessment. Multiple areas of cognition are assessed:
   • intelligence
   • academic functioning
   • attention
   • working memory
   • speed of processing
   • learning and memory
   • visual spatial skills
   • fine motor skills
   • executive functioning.

Essentially, the evaluation speaks to a patient’s neurocognitive functioning and cerebral integrity.

How are results scored? Interpretation of test scores is contingent on expectations of how a patient should perform in the absence of neurologic or psychiatric illness (ie, based on normative data and performancebased estimates of premorbid functioning).¹ The overall pattern of intact scores and deficit scores can be used to form specific impressions about a diagnosis, cognitive strengths and weaknesses, and strategies for intervention.

Personality testing. In addition to the cognitive aspect of the evaluation, personality measures are incorporated when relevant to the referral question or presenting concern.

Personality tests can be broadly divided into objective and projective measures.
Objective personality measures, such as the Minnesota Multiphasic Personality
Inventory-Second Edition, require the examinee to respond to a set of items as
true or false or on a Likert-type scale from strongly agree to disagree. Responses are then scored in standardized fashion, making comparisons to normative data, which are then analyzed to determine the extent to which the examinee experiences psychiatric symptoms.

As part of testing, patients’ responses to ambiguous or unstructured standard
stimuli—such as a series of drawings, abstract patterns, or incomplete sentences—
are analyzed to determine underlying personality traits, feelings, and attitudes.
Classic examples of these measures include the Rorschach Test and the Thematic
Apperception Test.

Personality measures and psychiatric testing are designed to answer questions
related to patients’ emotional status. These measures assess psychiatric symptoms and diagnoses, whereas neuropsychological measures provide an understanding of patients’ cognitive assets and limitations.

7 Common questions about neuropsychological testing

1 Will my patient’s insurance cover these assessments? The question is common from practitioners who are considering requesting an assessment for a patient. The short answer is “Yes.”

Most payers follow Medicare guidelines for reimbursement of neuropsychological
testing; if testing is determined to be medically necessary, insurance companies often cover the assessment. Medicaid also pays for psychometric testing services. Neuropsychologists who have a hospital-based practice typically include patients
with all types of insurance coverage. For example, 40% of patients seen in a hospital are covered by Medicare or Medicaid.²

A caveat: Local intermediaries interpret policies and procedures in different ways,
so there is variability in coverage by geographic region. That is why it is crucial
for neuropsychologists to obtain preauthorization, as would be the case with other medical procedures and services sought by referral.

Last, insurance companies do not pay for assessment of a learning disability. The
rationale typically offered for this lack of coverage? The assessment is for academic, not medical, purposes. In such a situation, patients and their families are offered a private-pay option.

2 What are the indications for neuropsychological assessment? Psychiatric practitioners are one of the top medical specialties that refer their patients for neuropsychological testing.³ This is because many patients with a psychiatric or
neurologic disorder experience changes in cognition, mood, and personality. Such
changes can range in severity from subtle to dramatic, and might reflect an underlying disease state or a side effect of medication or other treatment. Whatever the nature of a patient’s problem, careful assessment might help elucidate specific areas with which he (she) is struggling—so that you can better target your interventions. Table 1 lists common reasons for referring a patient for neuropsychological evaluation. Throughout this discussion, we describe examples of clinical situations in which neuropsychological testing is useful for establishing a differential diagnosis and dispositional planning.

3 How does neuropsychological testing help with the differential diagnosis? As an example, one area in which cognitive testing can be beneficial is in geriatric psychiatry.Dementia. Aging often is accompanied by a normal decline in memory and other cognitive functions. But because subtle changes in memory and cognition also canbe the sign of a progressive cognitive disorder, differentiating normal aging from early dementia is essential. Table 2 summarizes typical changes in cognition with aging.

Neuropsychologists, through knowledge of psychometric testing and the brain−behavior relationship, can help you detect dementia and plan treatment early. To determine if cognitive changes are progressive, patients might undergo re-evaluation—typically, every 6 to 12 months—to ascertain if changes have occurred. Mood disorders. Neuropsychological evaluation can be useful in building a differential diagnosis when determining whether cognitive symptoms are attributable to a mood disorder or a medical illness. Cognitive deficits associated with an affective disturbance generally include impairments in attention, memory, and executive functioning.⁴ The severity of deficits has been linked to severity of illness. When patients with a mood disorder demonstrate localizing impairments or those of greater severity than expected, suspicion arises that another cause likely better explains those deficits, and further medical testing then is often recommended. Medical procedures. Increasingly, neuropsychological assessment is used to assist in determining the appropriateness of medical procedures. For example, neurosurgical patients being considered for deep brain stimulation, brain tumor resectioning, and epilepsy surgery often are referred for preoperative and postoperative testing. Treating clinicians need an understanding of current cognitive status, localization of functioning, and psychological status to make appropriate decisions about a patient’s candidacy for one of these procedures,and to understand associated risk.

4 How is neuropsychological testing used for dispositional planning? The
results of cognitive and psychological testing have implications for dispositional
planning for patients who are receiving psychiatric care. The primary issue often is
to determine the patient’s level of independence and ability to make decisions about his affairs.⁵

Neuropsychological testing can help determine if cognitive deficits limit aspects of functional independence—for example, can the patient live alone, or must he live with family or in a residential care facility? Generally, the greater the cognitive impairment, the more supervision and assistance are required. This relationship between cognitive ability and independence in activities of daily living has been demonstrated in many groups of psychiatric patients, including older adults with dementia,⁶ patients with schizophrenia,⁷ and those with bipolar disorder.⁸

Specific recommendations can be made regarding management of finances, administering medications, and driving. To formulate an appropriate dispositional plan, the referring psychiatrist might integrate recommendations from the neuropsychological assessment with findings of other evaluations and with information that has been collected about the patient.

5 Can neuropsychological testing be used to refer a patient for neurological and cognitive rehabilitation? Yes. The neuropsychologist is singularly qualified to make recommendations about a range of interventions for cognitive deficits that have been identified on formal testing.

Typically, recommendations for addressing cognitive deficits involve rehabilitation
focused on development and use of compensatory strategies and modification to promote brain health.^9,10 Rehabilitation therapy typically is aimed at increasing functioning independence and reducing physical and cognitive deficits associated
with illness (eg, traumatic brain injury [TBI], stroke, orthopedic injury, debility).

Patients who have a TBI or who have had a stroke often have comorbid psychiatric problems, including mood and anxiety disorders, that can exacerbate deficits and impede engagement in rehabilitation. The neuropsychological evaluation can determine if this is the case and if psychiatric consultation is warranted to assist with managing symptoms.

Premorbid psychiatric illness can affect rehabilitation. Formal neuropsychological testing can assist with parsing out deficits associated with new-onset illness compared with premorbid psychiatric problems. The evaluation of a patient before he begins rehabilitation also can be compared with evaluations made during treatment and after discharge to 1) assess for changes and 2) update recommendations about management.

Recommendations about cognitive interventions might include specific compensatory strategies to address areas of weakness and capitalize on strengths. Such strategies can include using internal mnemonics, such as visual imagery (ie, using a visual image to help encode verbal information) or semantic elaboration (using semantic cues to aid in encoding and recall of information). Methods can help train patients to capitalize on areas of stronger cognitive functioning in compensating for their weaknesses; an example is the spaced-retrieval technique, which relies on repetition of information that is to be learned over time.¹¹

Perhaps the most practical strategies for addressing areas of weakness are nonmnemonic-based external memory aids, such as diaries, notebooks, calendars, alarms, and lists.¹² For example, for a patient with a TBI who has impaired memory, recommendations might include using written notes or a calendar system; using a pillbox for medication management; and using labels to promote structure and consistency in the home. These strategies are meant to promote increased independence and to minimize the effect of cognitive deficits on daily functioning.   

Recommended strategies can include lifestyle changes to promote improved cognitive functioning and overall health, such as:
   • sleep hygiene, to reduce the effects of fatigue
   • encouraging the patient to adhere to a diet, take prescribed medications, and  follow up with his health care providers
   • developing cognitive and physical exercise routines.

In addition, a patient who has had a stroke or who have a TBI might benefit from psychotherapy or referral to a group program or community resources to help cope with the effects of illness.¹³

6 How does neuropsychological testing help determine the appropriate psychiatric intervention for a patient? Results of neuropsychological testing can help determine appropriate interventions for a psychiatric condition that might be the principal factor affecting the patient’s functioning.

Concerning psychoactive medications, consider the following:

Mood and anxiety disorders. Neuropsychological measures can help substantiate the need for pharmacotherapy in a comorbid mood or anxiety disorder in a patient who has a neurologic illness, such as stroke or TBI.

ADHD. In a patient who has attentiondeficit/hyperactivity disorder (ADHD), results of cognitive testing might help determine if attention issues undermine daily functioning. Testing provides information beyond rating scale scores to justify diagnosis and psychopharmacotherapy.¹⁴

Dementia. Geriatric patients who have dementia often have coexisting behavioral and mood changes that, once evaluated, might improve with pharmacotherapy.

Other areas. Cognitive side effects of medications can be monitored by conducting testing before and after medication is started. The evaluation can address the patient’s ability to engage in psychotherapeutic interventions. Patients who have severe cognitive deficits might have greater difficulty engaging in psychotherapy, compared with patients who have less severe, or no, cognitive
impairment.¹⁵

7 Does neuropsychological testing help patients make return-to-work
and return-to-school decisions? Yes. Cognitive and psychiatric functioning have
implications for decisions about occupational and academic pursuits.

Patients who have severe cognitive or psychiatric symptoms might be or might not be able to maintain gainful employment or participate in school. Testing can help 1) document and justify disability and 2) establish recommendations about disability status. Those whose cognitive impairments or psychiatric symptoms are less severe might benefit from neuropsychological testing so that recommendations can be made regarding accommodations at work or in school, such as:
   • reduced work or school schedule
   • reduced level of occupational or academic demand
   • change in supervision or evaluation procedures by employer or school.

Cognitive strengths and weaknesses can be used to help a patient devise and implement compensatory strategies at work or school, such as:
   • note-taking
   • audio recording of meetings and lectures
   • using a calendar.

Patients sometimes benefit from formal vocational rehabilitation services to facilitate finding appropriate employment, returning to employment, and implementing workplace accommodations.


In conclusion

Neuropsychological evaluation, typically covered by health insurance, provides the
referring clinician with objective information about patients’ cognitive assets and limitations. In turn, this information can help you make a diagnosis and plan
treatment.

Unlike psychological testing, in which the patient is assessed for psychiatric
symptoms and conditions, neuropsychological measures offer insight into such
abilities as attention, memory, and reasoning. Neuropsychological evaluations also
can add insight to your determination of the cause of symptoms, thereby influencing decisions about medical therapy.

Last, these evaluations can aid with decision-making about dispositional planning
and whether adjunctive services, such as rehabilitation, would be of benefit.


Bottom Line

Neuropsychological assessments are a useful consultation to consider for patients
in a psychiatric setting. These evaluations can aid you in building and narrowing the differential diagnosis; identifying patients’ strengths and weakness; and making informed recommendations about functional independence.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Neuropsychological evaluation, consisting of a thorough examination of cognitive and behavioral functioning, can make an invaluable contribution to the care of psychiatric patients. Through the vehicle of standardized measures of abilities, patients’ cognitive strengths and weaknesses can be elucidated—revealing potential areas for further interventions or to explain impediments to treatment. A licensed clinical psychologist provides this service.

You, as a consumer of reported findings, can use the results to inform your diagnosis and treatment plan. Recommendations from the neuropsychologist often address dispositional planning, cognitive intervention, psychiatric intervention, and work and school accommodations.


Probing the brain−behavior relationship

Neuropsychology is a subspecialty of clinical psychology that is focused on understanding the brain–behavior relationship. Drawing information from multiple disciplines, including psychiatry and neurology, neuropsychology seeks to uncover the cognitive, behavioral, and emotional difficulties that can result from known or suspected brain dysfunction. Increasingly, to protect the public and referral sources, clinical psychologists who perform neuropsychological testing demonstrate their competence through board certification (eg, the American Board of Clinical Neuropsychology).

How is testing conducted? Evaluations comprise measures that are standardized, scored objectively, and have established psychometric properties. Testing can performed on an outpatient or inpatient basis; the duration of testing depends on the question for which the referring practitioner seeks an answer.

Measures typically are administered by paper and pencil, although computer-based
assessments are increasingly being employed. Because of the influence of demographic variables (age, sex, years of education, race), scores are compared with normative samples that resemble those of the patient’s background as closely as possible.

A thorough clinical interview with the patient, a collateral interview with caregivers
and family, and review of relevant medical records are crucial parts of the assessment. Multiple areas of cognition are assessed:
   • intelligence
   • academic functioning
   • attention
   • working memory
   • speed of processing
   • learning and memory
   • visual spatial skills
   • fine motor skills
   • executive functioning.

Essentially, the evaluation speaks to a patient’s neurocognitive functioning and cerebral integrity.

How are results scored? Interpretation of test scores is contingent on expectations of how a patient should perform in the absence of neurologic or psychiatric illness (ie, based on normative data and performancebased estimates of premorbid functioning).¹ The overall pattern of intact scores and deficit scores can be used to form specific impressions about a diagnosis, cognitive strengths and weaknesses, and strategies for intervention.

Personality testing. In addition to the cognitive aspect of the evaluation, personality measures are incorporated when relevant to the referral question or presenting concern.

Personality tests can be broadly divided into objective and projective measures.
Objective personality measures, such as the Minnesota Multiphasic Personality
Inventory-Second Edition, require the examinee to respond to a set of items as
true or false or on a Likert-type scale from strongly agree to disagree. Responses are then scored in standardized fashion, making comparisons to normative data, which are then analyzed to determine the extent to which the examinee experiences psychiatric symptoms.

As part of testing, patients’ responses to ambiguous or unstructured standard
stimuli—such as a series of drawings, abstract patterns, or incomplete sentences—
are analyzed to determine underlying personality traits, feelings, and attitudes.
Classic examples of these measures include the Rorschach Test and the Thematic
Apperception Test.

Personality measures and psychiatric testing are designed to answer questions
related to patients’ emotional status. These measures assess psychiatric symptoms and diagnoses, whereas neuropsychological measures provide an understanding of patients’ cognitive assets and limitations.

7 Common questions about neuropsychological testing

1 Will my patient’s insurance cover these assessments? The question is common from practitioners who are considering requesting an assessment for a patient. The short answer is “Yes.”

Most payers follow Medicare guidelines for reimbursement of neuropsychological
testing; if testing is determined to be medically necessary, insurance companies often cover the assessment. Medicaid also pays for psychometric testing services. Neuropsychologists who have a hospital-based practice typically include patients
with all types of insurance coverage. For example, 40% of patients seen in a hospital are covered by Medicare or Medicaid.²

A caveat: Local intermediaries interpret policies and procedures in different ways,
so there is variability in coverage by geographic region. That is why it is crucial
for neuropsychologists to obtain preauthorization, as would be the case with other medical procedures and services sought by referral.

Last, insurance companies do not pay for assessment of a learning disability. The
rationale typically offered for this lack of coverage? The assessment is for academic, not medical, purposes. In such a situation, patients and their families are offered a private-pay option.

2 What are the indications for neuropsychological assessment? Psychiatric practitioners are one of the top medical specialties that refer their patients for neuropsychological testing.³ This is because many patients with a psychiatric or
neurologic disorder experience changes in cognition, mood, and personality. Such
changes can range in severity from subtle to dramatic, and might reflect an underlying disease state or a side effect of medication or other treatment. Whatever the nature of a patient’s problem, careful assessment might help elucidate specific areas with which he (she) is struggling—so that you can better target your interventions. Table 1 lists common reasons for referring a patient for neuropsychological evaluation. Throughout this discussion, we describe examples of clinical situations in which neuropsychological testing is useful for establishing a differential diagnosis and dispositional planning.

3 How does neuropsychological testing help with the differential diagnosis? As an example, one area in which cognitive testing can be beneficial is in geriatric psychiatry.Dementia. Aging often is accompanied by a normal decline in memory and other cognitive functions. But because subtle changes in memory and cognition also canbe the sign of a progressive cognitive disorder, differentiating normal aging from early dementia is essential. Table 2 summarizes typical changes in cognition with aging.

Neuropsychologists, through knowledge of psychometric testing and the brain−behavior relationship, can help you detect dementia and plan treatment early. To determine if cognitive changes are progressive, patients might undergo re-evaluation—typically, every 6 to 12 months—to ascertain if changes have occurred. Mood disorders. Neuropsychological evaluation can be useful in building a differential diagnosis when determining whether cognitive symptoms are attributable to a mood disorder or a medical illness. Cognitive deficits associated with an affective disturbance generally include impairments in attention, memory, and executive functioning.⁴ The severity of deficits has been linked to severity of illness. When patients with a mood disorder demonstrate localizing impairments or those of greater severity than expected, suspicion arises that another cause likely better explains those deficits, and further medical testing then is often recommended. Medical procedures. Increasingly, neuropsychological assessment is used to assist in determining the appropriateness of medical procedures. For example, neurosurgical patients being considered for deep brain stimulation, brain tumor resectioning, and epilepsy surgery often are referred for preoperative and postoperative testing. Treating clinicians need an understanding of current cognitive status, localization of functioning, and psychological status to make appropriate decisions about a patient’s candidacy for one of these procedures,and to understand associated risk.

4 How is neuropsychological testing used for dispositional planning? The
results of cognitive and psychological testing have implications for dispositional
planning for patients who are receiving psychiatric care. The primary issue often is
to determine the patient’s level of independence and ability to make decisions about his affairs.⁵

Neuropsychological testing can help determine if cognitive deficits limit aspects of functional independence—for example, can the patient live alone, or must he live with family or in a residential care facility? Generally, the greater the cognitive impairment, the more supervision and assistance are required. This relationship between cognitive ability and independence in activities of daily living has been demonstrated in many groups of psychiatric patients, including older adults with dementia,⁶ patients with schizophrenia,⁷ and those with bipolar disorder.⁸

Specific recommendations can be made regarding management of finances, administering medications, and driving. To formulate an appropriate dispositional plan, the referring psychiatrist might integrate recommendations from the neuropsychological assessment with findings of other evaluations and with information that has been collected about the patient.

5 Can neuropsychological testing be used to refer a patient for neurological and cognitive rehabilitation? Yes. The neuropsychologist is singularly qualified to make recommendations about a range of interventions for cognitive deficits that have been identified on formal testing.

Typically, recommendations for addressing cognitive deficits involve rehabilitation
focused on development and use of compensatory strategies and modification to promote brain health.^9,10 Rehabilitation therapy typically is aimed at increasing functioning independence and reducing physical and cognitive deficits associated
with illness (eg, traumatic brain injury [TBI], stroke, orthopedic injury, debility).

Patients who have a TBI or who have had a stroke often have comorbid psychiatric problems, including mood and anxiety disorders, that can exacerbate deficits and impede engagement in rehabilitation. The neuropsychological evaluation can determine if this is the case and if psychiatric consultation is warranted to assist with managing symptoms.

Premorbid psychiatric illness can affect rehabilitation. Formal neuropsychological testing can assist with parsing out deficits associated with new-onset illness compared with premorbid psychiatric problems. The evaluation of a patient before he begins rehabilitation also can be compared with evaluations made during treatment and after discharge to 1) assess for changes and 2) update recommendations about management.

Recommendations about cognitive interventions might include specific compensatory strategies to address areas of weakness and capitalize on strengths. Such strategies can include using internal mnemonics, such as visual imagery (ie, using a visual image to help encode verbal information) or semantic elaboration (using semantic cues to aid in encoding and recall of information). Methods can help train patients to capitalize on areas of stronger cognitive functioning in compensating for their weaknesses; an example is the spaced-retrieval technique, which relies on repetition of information that is to be learned over time.¹¹

Perhaps the most practical strategies for addressing areas of weakness are nonmnemonic-based external memory aids, such as diaries, notebooks, calendars, alarms, and lists.¹² For example, for a patient with a TBI who has impaired memory, recommendations might include using written notes or a calendar system; using a pillbox for medication management; and using labels to promote structure and consistency in the home. These strategies are meant to promote increased independence and to minimize the effect of cognitive deficits on daily functioning.   

Recommended strategies can include lifestyle changes to promote improved cognitive functioning and overall health, such as:
   • sleep hygiene, to reduce the effects of fatigue
   • encouraging the patient to adhere to a diet, take prescribed medications, and  follow up with his health care providers
   • developing cognitive and physical exercise routines.

In addition, a patient who has had a stroke or who have a TBI might benefit from psychotherapy or referral to a group program or community resources to help cope with the effects of illness.¹³

6 How does neuropsychological testing help determine the appropriate psychiatric intervention for a patient? Results of neuropsychological testing can help determine appropriate interventions for a psychiatric condition that might be the principal factor affecting the patient’s functioning.

Concerning psychoactive medications, consider the following:

Mood and anxiety disorders. Neuropsychological measures can help substantiate the need for pharmacotherapy in a comorbid mood or anxiety disorder in a patient who has a neurologic illness, such as stroke or TBI.

ADHD. In a patient who has attentiondeficit/hyperactivity disorder (ADHD), results of cognitive testing might help determine if attention issues undermine daily functioning. Testing provides information beyond rating scale scores to justify diagnosis and psychopharmacotherapy.¹⁴

Dementia. Geriatric patients who have dementia often have coexisting behavioral and mood changes that, once evaluated, might improve with pharmacotherapy.

Other areas. Cognitive side effects of medications can be monitored by conducting testing before and after medication is started. The evaluation can address the patient’s ability to engage in psychotherapeutic interventions. Patients who have severe cognitive deficits might have greater difficulty engaging in psychotherapy, compared with patients who have less severe, or no, cognitive
impairment.¹⁵

7 Does neuropsychological testing help patients make return-to-work
and return-to-school decisions? Yes. Cognitive and psychiatric functioning have
implications for decisions about occupational and academic pursuits.

Patients who have severe cognitive or psychiatric symptoms might be or might not be able to maintain gainful employment or participate in school. Testing can help 1) document and justify disability and 2) establish recommendations about disability status. Those whose cognitive impairments or psychiatric symptoms are less severe might benefit from neuropsychological testing so that recommendations can be made regarding accommodations at work or in school, such as:
   • reduced work or school schedule
   • reduced level of occupational or academic demand
   • change in supervision or evaluation procedures by employer or school.

Cognitive strengths and weaknesses can be used to help a patient devise and implement compensatory strategies at work or school, such as:
   • note-taking
   • audio recording of meetings and lectures
   • using a calendar.

Patients sometimes benefit from formal vocational rehabilitation services to facilitate finding appropriate employment, returning to employment, and implementing workplace accommodations.


In conclusion

Neuropsychological evaluation, typically covered by health insurance, provides the
referring clinician with objective information about patients’ cognitive assets and limitations. In turn, this information can help you make a diagnosis and plan
treatment.

Unlike psychological testing, in which the patient is assessed for psychiatric
symptoms and conditions, neuropsychological measures offer insight into such
abilities as attention, memory, and reasoning. Neuropsychological evaluations also
can add insight to your determination of the cause of symptoms, thereby influencing decisions about medical therapy.

Last, these evaluations can aid with decision-making about dispositional planning
and whether adjunctive services, such as rehabilitation, would be of benefit.


Bottom Line

Neuropsychological assessments are a useful consultation to consider for patients
in a psychiatric setting. These evaluations can aid you in building and narrowing the differential diagnosis; identifying patients’ strengths and weakness; and making informed recommendations about functional independence.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.

Neuropsychological evaluation, consisting of a thorough examination of cognitive and behavioral functioning, can make an invaluable contribution to the care of psychiatric patients. Through the vehicle of standardized measures of abilities, patients’ cognitive strengths and weaknesses can be elucidated—revealing potential areas for further interventions or to explain impediments to treatment. A licensed clinical psychologist provides this service.

You, as a consumer of reported findings, can use the results to inform your diagnosis and treatment plan. Recommendations from the neuropsychologist often address dispositional planning, cognitive intervention, psychiatric intervention, and work and school accommodations.


Probing the brain−behavior relationship

Neuropsychology is a subspecialty of clinical psychology that is focused on understanding the brain–behavior relationship. Drawing information from multiple disciplines, including psychiatry and neurology, neuropsychology seeks to uncover the cognitive, behavioral, and emotional difficulties that can result from known or suspected brain dysfunction. Increasingly, to protect the public and referral sources, clinical psychologists who perform neuropsychological testing demonstrate their competence through board certification (eg, the American Board of Clinical Neuropsychology).

How is testing conducted? Evaluations comprise measures that are standardized, scored objectively, and have established psychometric properties. Testing can performed on an outpatient or inpatient basis; the duration of testing depends on the question for which the referring practitioner seeks an answer.

Measures typically are administered by paper and pencil, although computer-based
assessments are increasingly being employed. Because of the influence of demographic variables (age, sex, years of education, race), scores are compared with normative samples that resemble those of the patient’s background as closely as possible.

A thorough clinical interview with the patient, a collateral interview with caregivers
and family, and review of relevant medical records are crucial parts of the assessment. Multiple areas of cognition are assessed:
   • intelligence
   • academic functioning
   • attention
   • working memory
   • speed of processing
   • learning and memory
   • visual spatial skills
   • fine motor skills
   • executive functioning.

Essentially, the evaluation speaks to a patient’s neurocognitive functioning and cerebral integrity.

How are results scored? Interpretation of test scores is contingent on expectations of how a patient should perform in the absence of neurologic or psychiatric illness (ie, based on normative data and performancebased estimates of premorbid functioning).¹ The overall pattern of intact scores and deficit scores can be used to form specific impressions about a diagnosis, cognitive strengths and weaknesses, and strategies for intervention.

Personality testing. In addition to the cognitive aspect of the evaluation, personality measures are incorporated when relevant to the referral question or presenting concern.

Personality tests can be broadly divided into objective and projective measures.
Objective personality measures, such as the Minnesota Multiphasic Personality
Inventory-Second Edition, require the examinee to respond to a set of items as
true or false or on a Likert-type scale from strongly agree to disagree. Responses are then scored in standardized fashion, making comparisons to normative data, which are then analyzed to determine the extent to which the examinee experiences psychiatric symptoms.

As part of testing, patients’ responses to ambiguous or unstructured standard
stimuli—such as a series of drawings, abstract patterns, or incomplete sentences—
are analyzed to determine underlying personality traits, feelings, and attitudes.
Classic examples of these measures include the Rorschach Test and the Thematic
Apperception Test.

Personality measures and psychiatric testing are designed to answer questions
related to patients’ emotional status. These measures assess psychiatric symptoms and diagnoses, whereas neuropsychological measures provide an understanding of patients’ cognitive assets and limitations.

7 Common questions about neuropsychological testing

1 Will my patient’s insurance cover these assessments? The question is common from practitioners who are considering requesting an assessment for a patient. The short answer is “Yes.”

Most payers follow Medicare guidelines for reimbursement of neuropsychological
testing; if testing is determined to be medically necessary, insurance companies often cover the assessment. Medicaid also pays for psychometric testing services. Neuropsychologists who have a hospital-based practice typically include patients
with all types of insurance coverage. For example, 40% of patients seen in a hospital are covered by Medicare or Medicaid.²

A caveat: Local intermediaries interpret policies and procedures in different ways,
so there is variability in coverage by geographic region. That is why it is crucial
for neuropsychologists to obtain preauthorization, as would be the case with other medical procedures and services sought by referral.

Last, insurance companies do not pay for assessment of a learning disability. The
rationale typically offered for this lack of coverage? The assessment is for academic, not medical, purposes. In such a situation, patients and their families are offered a private-pay option.

2 What are the indications for neuropsychological assessment? Psychiatric practitioners are one of the top medical specialties that refer their patients for neuropsychological testing.³ This is because many patients with a psychiatric or
neurologic disorder experience changes in cognition, mood, and personality. Such
changes can range in severity from subtle to dramatic, and might reflect an underlying disease state or a side effect of medication or other treatment. Whatever the nature of a patient’s problem, careful assessment might help elucidate specific areas with which he (she) is struggling—so that you can better target your interventions. Table 1 lists common reasons for referring a patient for neuropsychological evaluation. Throughout this discussion, we describe examples of clinical situations in which neuropsychological testing is useful for establishing a differential diagnosis and dispositional planning.

3 How does neuropsychological testing help with the differential diagnosis? As an example, one area in which cognitive testing can be beneficial is in geriatric psychiatry.Dementia. Aging often is accompanied by a normal decline in memory and other cognitive functions. But because subtle changes in memory and cognition also canbe the sign of a progressive cognitive disorder, differentiating normal aging from early dementia is essential. Table 2 summarizes typical changes in cognition with aging.

Neuropsychologists, through knowledge of psychometric testing and the brain−behavior relationship, can help you detect dementia and plan treatment early. To determine if cognitive changes are progressive, patients might undergo re-evaluation—typically, every 6 to 12 months—to ascertain if changes have occurred. Mood disorders. Neuropsychological evaluation can be useful in building a differential diagnosis when determining whether cognitive symptoms are attributable to a mood disorder or a medical illness. Cognitive deficits associated with an affective disturbance generally include impairments in attention, memory, and executive functioning.⁴ The severity of deficits has been linked to severity of illness. When patients with a mood disorder demonstrate localizing impairments or those of greater severity than expected, suspicion arises that another cause likely better explains those deficits, and further medical testing then is often recommended. Medical procedures. Increasingly, neuropsychological assessment is used to assist in determining the appropriateness of medical procedures. For example, neurosurgical patients being considered for deep brain stimulation, brain tumor resectioning, and epilepsy surgery often are referred for preoperative and postoperative testing. Treating clinicians need an understanding of current cognitive status, localization of functioning, and psychological status to make appropriate decisions about a patient’s candidacy for one of these procedures,and to understand associated risk.

4 How is neuropsychological testing used for dispositional planning? The
results of cognitive and psychological testing have implications for dispositional
planning for patients who are receiving psychiatric care. The primary issue often is
to determine the patient’s level of independence and ability to make decisions about his affairs.⁵

Neuropsychological testing can help determine if cognitive deficits limit aspects of functional independence—for example, can the patient live alone, or must he live with family or in a residential care facility? Generally, the greater the cognitive impairment, the more supervision and assistance are required. This relationship between cognitive ability and independence in activities of daily living has been demonstrated in many groups of psychiatric patients, including older adults with dementia,⁶ patients with schizophrenia,⁷ and those with bipolar disorder.⁸

Specific recommendations can be made regarding management of finances, administering medications, and driving. To formulate an appropriate dispositional plan, the referring psychiatrist might integrate recommendations from the neuropsychological assessment with findings of other evaluations and with information that has been collected about the patient.

5 Can neuropsychological testing be used to refer a patient for neurological and cognitive rehabilitation? Yes. The neuropsychologist is singularly qualified to make recommendations about a range of interventions for cognitive deficits that have been identified on formal testing.

Typically, recommendations for addressing cognitive deficits involve rehabilitation
focused on development and use of compensatory strategies and modification to promote brain health.^9,10 Rehabilitation therapy typically is aimed at increasing functioning independence and reducing physical and cognitive deficits associated
with illness (eg, traumatic brain injury [TBI], stroke, orthopedic injury, debility).

Patients who have a TBI or who have had a stroke often have comorbid psychiatric problems, including mood and anxiety disorders, that can exacerbate deficits and impede engagement in rehabilitation. The neuropsychological evaluation can determine if this is the case and if psychiatric consultation is warranted to assist with managing symptoms.

Premorbid psychiatric illness can affect rehabilitation. Formal neuropsychological testing can assist with parsing out deficits associated with new-onset illness compared with premorbid psychiatric problems. The evaluation of a patient before he begins rehabilitation also can be compared with evaluations made during treatment and after discharge to 1) assess for changes and 2) update recommendations about management.

Recommendations about cognitive interventions might include specific compensatory strategies to address areas of weakness and capitalize on strengths. Such strategies can include using internal mnemonics, such as visual imagery (ie, using a visual image to help encode verbal information) or semantic elaboration (using semantic cues to aid in encoding and recall of information). Methods can help train patients to capitalize on areas of stronger cognitive functioning in compensating for their weaknesses; an example is the spaced-retrieval technique, which relies on repetition of information that is to be learned over time.¹¹

Perhaps the most practical strategies for addressing areas of weakness are nonmnemonic-based external memory aids, such as diaries, notebooks, calendars, alarms, and lists.¹² For example, for a patient with a TBI who has impaired memory, recommendations might include using written notes or a calendar system; using a pillbox for medication management; and using labels to promote structure and consistency in the home. These strategies are meant to promote increased independence and to minimize the effect of cognitive deficits on daily functioning.   

Recommended strategies can include lifestyle changes to promote improved cognitive functioning and overall health, such as:
   • sleep hygiene, to reduce the effects of fatigue
   • encouraging the patient to adhere to a diet, take prescribed medications, and  follow up with his health care providers
   • developing cognitive and physical exercise routines.

In addition, a patient who has had a stroke or who have a TBI might benefit from psychotherapy or referral to a group program or community resources to help cope with the effects of illness.¹³

6 How does neuropsychological testing help determine the appropriate psychiatric intervention for a patient? Results of neuropsychological testing can help determine appropriate interventions for a psychiatric condition that might be the principal factor affecting the patient’s functioning.

Concerning psychoactive medications, consider the following:

Mood and anxiety disorders. Neuropsychological measures can help substantiate the need for pharmacotherapy in a comorbid mood or anxiety disorder in a patient who has a neurologic illness, such as stroke or TBI.

ADHD. In a patient who has attentiondeficit/hyperactivity disorder (ADHD), results of cognitive testing might help determine if attention issues undermine daily functioning. Testing provides information beyond rating scale scores to justify diagnosis and psychopharmacotherapy.¹⁴

Dementia. Geriatric patients who have dementia often have coexisting behavioral and mood changes that, once evaluated, might improve with pharmacotherapy.

Other areas. Cognitive side effects of medications can be monitored by conducting testing before and after medication is started. The evaluation can address the patient’s ability to engage in psychotherapeutic interventions. Patients who have severe cognitive deficits might have greater difficulty engaging in psychotherapy, compared with patients who have less severe, or no, cognitive
impairment.¹⁵

7 Does neuropsychological testing help patients make return-to-work
and return-to-school decisions? Yes. Cognitive and psychiatric functioning have
implications for decisions about occupational and academic pursuits.

Patients who have severe cognitive or psychiatric symptoms might be or might not be able to maintain gainful employment or participate in school. Testing can help 1) document and justify disability and 2) establish recommendations about disability status. Those whose cognitive impairments or psychiatric symptoms are less severe might benefit from neuropsychological testing so that recommendations can be made regarding accommodations at work or in school, such as:
   • reduced work or school schedule
   • reduced level of occupational or academic demand
   • change in supervision or evaluation procedures by employer or school.

Cognitive strengths and weaknesses can be used to help a patient devise and implement compensatory strategies at work or school, such as:
   • note-taking
   • audio recording of meetings and lectures
   • using a calendar.

Patients sometimes benefit from formal vocational rehabilitation services to facilitate finding appropriate employment, returning to employment, and implementing workplace accommodations.


In conclusion

Neuropsychological evaluation, typically covered by health insurance, provides the
referring clinician with objective information about patients’ cognitive assets and limitations. In turn, this information can help you make a diagnosis and plan
treatment.

Unlike psychological testing, in which the patient is assessed for psychiatric
symptoms and conditions, neuropsychological measures offer insight into such
abilities as attention, memory, and reasoning. Neuropsychological evaluations also
can add insight to your determination of the cause of symptoms, thereby influencing decisions about medical therapy.

Last, these evaluations can aid with decision-making about dispositional planning
and whether adjunctive services, such as rehabilitation, would be of benefit.


Bottom Line

Neuropsychological assessments are a useful consultation to consider for patients
in a psychiatric setting. These evaluations can aid you in building and narrowing the differential diagnosis; identifying patients’ strengths and weakness; and making informed recommendations about functional independence.

Disclosure
The authors report no financial relationships with any company whose products are mentioned in this article or with manufacturers of competing products.