A Novel Nephropsychology Clinic: Partnering With Patients in the Era of Value-Based Care in Nephrology.

CKD and end-stage kidney disease are highly prevalent and complex chronic conditions with a high disease burden that corresponds to a high cost of care. Mental health conditions have a high prevalence in this population and add to the burden of disease, increase the cost of care, and are co-related with worse clinical outcomes. Despite these clear co-relations, mental health disorders remain underdiagnosed and undertreated in this population, secondary to multiple reasons, including patient-specific factors as well as systematic issues, including difficulty in accessing mental health experts. Here we describe a novel collaborative care model for patients with advanced CKD within the nephrology clinic space, in the form of a nephropsychology clinic. We present the details of our clinic, our preliminary findings, and propose that an integrated behavioral health model offers convenience for the patient and improves workflow for the physician, allowing a pathway to timely mental health interventions.

Using a tele-behavioral health rapid intake model to address high demand for psychotherapy at an academic medical center during COVID-19.

Background: Long wait times for mental health appointments have been a chronic dilemma for academic medical centers. This problem intensified worldwide with the onset of the COVID-19 pandemic. Approximately 70% of mental health services experienced pandemic-related disruption in care provision, while simultaneously experiencing a substantial increase in patient demand. Wait times for mental health appointments also increased, varying across populations from 3 to 18 months. As prolonged wait time is positively associated with severity of psychiatric symptoms and negative outcomes, the authors implemented a novel rapid intake telemedicine clinic model to shorten wait time and increase patient access to psychological care at an academic medical center. Methods: To address an overwhelming influx of mental health referrals and a growing wait-time-until-first appointment at an academic medical center serving as a lone safety net hospital during the COVID-19 pandemic, a 5-provider Psychology Rapid Intake Team was established using a hybrid of telehealth and in-person appointments based on patient preference. Data on new patient volumes, wait time for 1st appointment, and wait time to begin therapeutic intervention were compared during the same calendar 3-month period immediately prior to and following implementation of the rapid intake clinic. Results: A paired-samples t-test was conducted to compare new patient volumes pre- vs. post- intervention. Results revealed a significant increase in the number of new patients the providers were able to accommodate in the post-implementation (M = 62.00, SD = 7.21) compared to the pre-implementation (M = 31.00, SD = 2.61) condition; t(2) = -8.60, p < 0.05. There was a significant decrease in the average wait times for 1st appointment post-implementation (M = 24.99, SD = 2.38) compared to the pre-implementation (M = 37.32, SD = 1.47) condition; t(2) = 5.56, p < 0.05. In addition, days to begin therapeutic intervention decreased dramatically (394%) from the pre- (M = 142.50) to post-implementation (M = 28.84) period. Conclusion: The COVID-19 pandemic strained a mental healthcare system which led to increasingly long wait times for intake appointments and delayed psychotherapy interventions. The Psychology Rapid Intake Team initiative served to improve access, reduce patient risk related to prolonged wait times, and accelerated patient engagement with psychotherapy services. The model can serve as a unique, sustainable infrastructure for behavioral health delivery for low acuity mental health problems in large health care systems.

Case Study: A Precision Medicine Approach to Multifactorial Dementia and Alzheimer's Disease.

We report a case of a patient with mixed dementia successfully treated with a personalized multimodal therapy. Monotherapeutics are inadequate for the treatment of Alzheimer's disease (AD) and mixed dementia; therefore, we approach treatment through an adaptive personalized multimodal program. Many multimodal programs are pre-determined, and thus may not address the underlying contributors to cognitive decline in each particular individual. The combination of a targeted, personalized, precision medicine approach using a multimodal program promises advantages over monotherapies and untargeted multimodal therapies for multifactorial dementia. In this case study, we describe successful treatment for a patient diagnosed with AD, using a multimodal, programmatic, precision medicine intervention encompassing therapies targeting multiple dementia diastheses. We describe specific interventions used in this case that are derived from a comprehensive protocol for AD precision medicine. After treatment, our patient demonstrated improvements in quantitative neuropsychological testing, volumetric neuroimaging, PET scans, and serum chemistries, accompanied by symptomatic improvement over a 3.5-year period. This case outcome supports the need for rigorous trials of comprehensive, targeted combination therapies to stabilize, restore, and prevent cognitive decline in individuals with potentially many underlying causes of such decline and dementia. Our multimodal therapy included personalized treatments to address each potential perturbation to neuroplasticity. In particular, neuroinflammation and metabolic subsystems influence cognitive function and hippocampal volume. In this patient with a primary biliary cholangitis (PBC) multimorbidity component, we introduced a personalized diet that helped reduce liver inflammation. Together, all these components of multimodal therapy showed a sustained functional and cognitive benefit. Multimodal therapies may have systemwide benefits on all dementias, particularly in the context of multimorbidity. Furthermore, these therapies provide generalized health benefits, as many of the factors - such as inflammation - that impact cognitive function also impact other systems.

Effects of transcranial direct current stimulation (tDCS) on binge eating disorder.

OBJECTIVE: To investigate the effect of transcranial direct current stimulation (tDCS) on food craving, intake, binge eating desire, and binge eating frequency in individuals with binge eating disorder (BED). METHOD: N = 30 adults with BED or subthreshold BED received a 20-min 2 milliampere (mA) session of tDCS targeting the dorsolateral prefrontal cortex (DLPFC; anode right/cathode left) and a sham session. Food image ratings assessed food craving, a laboratory eating test assessed food intake, and an electronic diary recorded binge variables. RESULTS: tDCS versus sham decreased craving for sweets, savory proteins, and an all-foods category, with strongest reductions in men (p < 0.05). tDCS also decreased total and preferred food intake by 11 and 17.5%, regardless of sex (p < 0.05), and reduced desire to binge eat in men on the day of real tDCS administration (p < 0.05). The reductions in craving and food intake were predicted by eating less frequently for reward motives, and greater intent to restrict calories, respectively. DISCUSSION: This proof of concept study is the first to find ameliorating effects of tDCS in BED. Stimulation of the right DLPFC suggests that enhanced cognitive control and/or decreased need for reward may be possible functional mechanisms. The results support investigation of repeated tDCS as a safe and noninvasive treatment adjunct for BED. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:930-936).

Assessment of veteran and caregiver knowledge about mild traumatic brain injury in a VA Medical Center.

OBJECTIVE: To examine the accuracy of knowledge about mild traumatic brain injury (TBI) of veterans and their friends/family members. SETTING: VA Medical Center. PARTICIPANTS: One hundred veterans and 50 of their friends/family members. DESIGN: Cross-sectional survey. MAIN MEASURES: A 60-item questionnaire was created by drawing both from the Neurobehavioral Symptom Inventory and from a brain injury knowledge survey developed for use with the general public. RESULTS: Both groups were equally able to identify true mild TBI items, but both also endorsed numerous items not typical of a mild injury. Self-reported prior TBI and receipt of TBI education were unrelated to the level of knowledge. For both groups, knowing another individual with TBI was unrelated to other aspects of mild TBI knowledge. Only 1 in 5 veterans endorsed receiving brain injury education while in the military. CONCLUSION: Results of this study may assist in the development of targeted TBI educational interventions for veterans and their friends/family members within the Veterans Affairs system. Ultimately, increased knowledge about mild TBI improves the likelihood that veterans receive care congruent with their needs and may potentially improve outcomes for those with mild TBI.

A biopsychosocial approach to liver transplant evaluation in two patients with Wilson's disease.

Wilson's disease (WD) is characterized by hepatic, neurological, and/or psychiatric disturbances. In some cases, liver transplantation is indicated. Because psychologists and other health care workers play an increasing role in the evaluation of individuals presenting for transplant, an understanding of the heterogeneous phenotype of WD is important for mental health professionals working in medical settings. This article reviews two cases of patients with WD (one probable, one confirmed) presenting for liver transplantation and a biopsychosocial assessment approach is demonstrated. Patients are presented in terms of medical, psychiatric, and psychosocial history, neuropsychological examination results, and the subsequent indications for liver transplantation. Both patients exhibited neurocognitive and psychiatric symptoms. One patient was determined to be a marginally suitable candidate for transplantation, whereas the other was considered at high risk for negative outcome post-transplant. This article demonstrates the importance of considering phenotypic presentation, neurocognitive function, psychiatric status, and psychosocial circumstances in assessing transplant readiness in patients with WD. A comprehensive and integrative biopsychosocial assessment approach is appropriate for evaluating patients with WD presenting for liver transplantation.

Psychosocial predictors of intentions to comply with bariatric surgery guidelines.

An increasing body of research suggests that many patients have difficulty adopting the eating guidelines after weight-loss surgery, thereby reducing the long-term success of the procedure. Given such difficulties, it is possible that the typical preoperative education regarding post-surgical eating behavior guidelines is ineffective in motivating some individuals to comply. Presently, no accurate predictors of intentions to comply with post-bariatric surgery guidelines have been identified. In the present pilot study, a psychosocial intervention based on protection motivation theory (PMT) was presented to patients undergoing bariatric surgery. PMT is a well-established preventive health model that has been utilized in a variety of health domains. Participants for this study were recruited before undergoing bariatric surgery, and were randomly assigned to one of two groups: PMT group vs. control. In addition to routine messages from the bariatric surgeon, participants in the PMT group received an intervention based in PMT that focused on the importance of adhering to post-surgical eating behavior guidelines and how best to adhere to these guidelines. Participants in the control group received standard of care information from the bariatric surgeon. Results indicated that the PMT intervention did not have a significant impact. However, follow-up analyses revealed that two aspects of PMT, perceived self-efficacy and perceived threat of not following the guidelines, predicted patients' intentions to comply with post-surgical guidelines. Findings are discussed in terms of the methodological compromises that resulted from the applied research setting as well as promising avenues for future investigation.

Cognitive performance of morbidly obese patients seeking bariatric surgery.

Bariatric surgery is efficacious for the treatment of severe obesity; however, little empirical research exists describing the demographic, psychosocial, and cognitive characteristics of patients presenting for the surgery. One hundred and sixty-nine morbidly obese patients seeking bariatric surgery underwent a presurgical psychological assessment, including cognitive testing. Morbidly obese individuals seeking bariatric surgery were similar in education, income status, and IQ compared with normative data. IQ was average, did not correlate with body mass index, and reflected a normal distribution. As a group, bariatric surgery patients endorsed minimal levels of depression and low levels of psychopathology. Obese individuals did demonstrate specific cognitive deficits on tests of executive function (e.g., problem solving and planning) when compared with normative data. This data suggests that bariatric surgery patients differ very little from other surgical populations on most demographic and psychosocial variables. The data does provide evidence for specific cognitive deficits in the area of executive functions at baseline in morbidly obese adults seeking bariatric surgery.

Evidence of executive dysfunction in extremely obese adolescents: a pilot study.

BACKGROUND: Obesity in children and adolescents is 1 of the most urgent and serious health threats confronting the United States. Extremely obese adolescents (body mass index >99th percentile for age and gender) are a unique subgroup of obese youth who are at considerable medical and psychosocial risk. Little is known about the cognitive function of extremely obese adolescents. The present study sought to examine the cognitive performance of a sample of extremely obese adolescents seeking primary treatment for weight loss. METHODS: Adolescents were recruited during regularly scheduled medical appointments at a children's center for weight management associated with a major children's hospital in the Southeast United States. A computerized battery of cognitive tests was administered to obese adolescents (body mass index >99th percentile; n = 25). RESULTS: Obese adolescents exhibited deficits in many cognitive domains, including impairment in attention and executive functions (e.g., mental flexibility, disinhibition) compared with the normative data. CONCLUSION: Although preliminary, these data have provided evidence for specific cognitive deficits in extremely obese adolescents. These findings highlight a need to determine whether early weight loss interventions, such as bariatric surgery, for obese adolescents could potentially prevent or reverse cognitive deficits and/or reduce the risk of future adverse neurocognitive outcome.

Bulimic symptoms and body image dissatisfaction in college women: more affected by climate or race?

The authors examined bulimic symptoms and body image dissatisfaction (BID) in a sample of college women. No differences were found in comparisons of bulimic symptoms or BID between Southern and Northern White women, and both groups reported similar levels of awareness and internalization of sociocultural aesthetic standards of appearance. Southeastern Black women reported (a) significantly lower levels of bulimic symptoms in comparison with White women from the North and (b) lower levels of BID in comparison with White women from both Southern and Northern regions. Further, Southeastern Black women were significantly less likely to be aware of and endorse mainstream standards of appearance in comparison with both groups of White women. Findings support the hypothesis that having a positive body image and less susceptibility to mainstream aesthetic standards of appearance may reduce the risk of eating disorder pathology in Black women.

Neuropsychological performance of a clinical sample of extremely obese individuals.

Obesity is a leading cause of preventable death in America and its prevalence is increasing at an alarming rate. While it is known that individuals with specific obesity-related medical conditions perform poorly on neuropsychological tasks, recent evidence suggests that cognitive dysfunction in obese individuals may occur independently of medical co-morbidities. This study examined neuropsychological performance in a clinical sample of extremely obese patients. Individuals seeking surgical treatment of obesity (N=68) were administered cognitive tests as part of a standard pre-surgical evaluation. Results indicated significant differences in performances of extremely obese individuals on tests of executive functioning (planning, problem solving, mental flexibility) in comparison to normative data. No significant differences emerged between obese patients with and without co-morbid medical conditions of hypertension, type II diabetes, and obstructive sleep apnea on the neuropsychological tasks specific to executive functioning. Taken together, these results provide further evidence of specific cognitive dysfunction in extremely obese individuals.

Body dissatisfaction, bulimic symptoms, and clothing practices among college women.

Clothing use may be a behavioral avoidance strategy for individuals with body dissatisfaction and eating pathology. The authors administered the Body Image Avoidance Questionnaire (J. C. Rosen, D. Srebnik, E. Saltzberg, & S. Wendt, 1991), the Bulimia Test-Revised (M. Thelen, J. Farmer, S. Wonderlich, & M. Smith, 1991), and the Body dissatisfaction subscale of the Eating Disorder Inventory (D. M. Garner, M. P. Olmstead, & J. Polivy, 1983) to undergraduate college women from two universities (N = 540). Results indicated that women who were more dissatisfied with their bodies (beta = .396) and had greater disordered eating behaviors (beta = .378) were more likely to engage in clothing-related appearance-management behaviors (p < .001), including wearing apparel to camouflage their bodies; avoiding revealing, brightly colored, or tightly fitting clothing; and avoiding shopping for clothing. These findings suggest that the presence of certain clothing-related appearance-management behaviors may be a warning sign that an individual is at risk for developing an eating disorder or may currently have an eating disorder.

The relationship between menopausal status, phase of menstrual cycle, and replacement estrogen on cognition in healthy women without dementia.

The authors examined the effect of menopausal status on several aspects of cognition in 4 groups of women (young premenopausal women, middle-aged premenopausal women, naturally postmenopausal women not using hormone therapy, and postmenopausal women using hormone replacement therapy). Participants (N = 48) completed questionnaires designed to assess psychological and physical health. The authors administered a test battery consisting of 10 neuropsychological tests to assess cognitive functioning. Using multivariate analyses of covariance with age as the covariate, the authors found a significant main effect of menopausal status on attention and complex processing abilities. Postmenopausal women using hormone replacement therapy significantly outperformed postmenopausal women not using hormone therapy on the Trail Making Test, Part B of the Halstead-Reitan (R. M. Reitan, 1958). This effect was significant even when the authors controlled for the effects of age, vocabulary levels, and education. Results are consistent with previous findings and may provide further evidence for an ameliorative effect of estrogen replacement therapy on specific cognitive functions.

The Iowa gambling task as a measure of decision making in women with bulimia nervosa.

Persistent chaotic feeding behavior (i.e., bingeing and purging), despite consequent adverse health and psychosocial consequences, is central to the definition and diagnosis of bulimia nervosa (BN). Repeatedly choosing immediate short-term gratification when long-term consequences are deleterious may reflect deficits in decision-making ability. However, to date, there has been no systematic examination of decision-making ability in individuals diagnosed with BN. In the present study, 20 undergraduate women with minimal bulimic symptoms (Control Group) and 20 with a diagnosis of BN (BN Group) were administered the Iowa Gambling Task (GT). Results indicated that the BN Group performed significantly worse on the GT in comparison to the Control Group and GT performance was negatively correlated with bulimic symptomatology. The presence of BN symptoms also predicted GT performance above and beyond demographic variables and depressive symptoms. These findings provide evidence for the presence of decision-making deficits in individuals with BN.

Gender differences in body size dissatisfaction among individuals with low, medium, or high levels of body focus.

The authors designed the present study to test whether women reported higher levels of body dissatisfaction than did men even when the 2 genders were matched on a measure of degree of body focus. Sixty undergraduates (30 men, 30 women) were screened on attention-to-body-shape scores and divided into high, medium, and low body-shape-focus groups. The participants also completed questionnaires that provided information on age, education, vocabulary ability, levels of depression, and body-image assessment. The groups did not differ (ps > .05) on age, education, vocabulary ability, or levels of depression. However, women in all 3 body-shape-focus categories indicated a larger discrepancy between their real vs. ideal body images (p < .01) than did the men. In the high-body-focus group, there was an 11:1ratio between women's and men's reported real-ideal body-shape discrepancies. Women showed greater body dissatisfaction than did men, even when the genders were matched on a measure of body focus.

End-of Life Issues in the Context of Alzheimer's Disease.

This article presents an overview of end-of-life care for individuals with Alzheimer's disease (AD) and their family caregivers. We define end-stage AD, and review neuropsychological and behavioral characteristics along with concomitant issues in therapeutic assessment. We then review the literature regarding programs and treatments for end-stage AD, the need for advance care planning and family participation in medical decision-making, familial caregiving stress, and issues associated with palliative care and bereavement outcomes. Methodological issues in the extant research literature are addressed, including issues of treatment implementation, validity, and clinical significance. Translational research and demonstration projects are encouraged.