The Wiley Encyclopedia

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Clinical Health Psychology
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10 9 8 7 6 5 4 3 2 1
 Psychological Assessment in Medical
Settings: Overview and Practice
Implications
Kelsey A. Maloney and Adam T. Schmidt
Department of Psychological Sciences, Texas Tech University, Lubbock, TX, USA

The field of health psychology is a rapidly changing and expanding area of clinical and research
focus. Skills of psychologists are increasingly being utilized in medical settings, including
­primary care, rehabilitation, and specialty medical clinics including oncology, cardiology, and
organ transplantation. Approximately 60 medical disorders frequently encountered in primary
care settings can also cause or exacerbate mental health conditions (Kush, 2001). Many pri-
mary care physicians may not have sufficient time to routinely detect, diagnose, or provide
treatment for common psychological problems in their patients; moreover, many referrals that
are made are not followed‐up on by patients because of constraints of access, insurance cover-
age, or unfamiliarity with mental health assessment and intervention. Because so many
­common medical disorders impact mental health and vice versa, many physicians are begin-
ning to work collaboratively with psychologists as part of a multidisciplinary treatment team in
order to provide holistic, integrated care to their patients. Through the formal assessment of
psychological symptoms, psychologists can help turn the focus of treatment either to or away
from primary psychological issues and help streamline treatment for patients (Kush, 2001).
Anxiety disorders, followed by depressive disorders, are the most common presenting
­problems for mental health professionals practicing across medical settings. Both the occur-
rence of anxiety and depression can complicate treatment of other health conditions either by
interfering with reporting of symptoms, reducing compliance with medically recommended
treatments, or by contributing to behaviors that complicate the course of the medical ailment
(e.g., a patient smokes to reduce stress caused by anxiety thereby exacerbating their cardiovas-
cular disease). Not only can primary medical concerns be complicated by secondary mental
health disorders, but primary mental health concerns can also be complicated with secondary
medical disorders. Psychologists can provide a more thorough description of a patient’s

The Wiley Encyclopedia of Health Psychology: Volume 3: Clinical Health Psychology and Behavioral Medicine,
First Edition. General Editor: Lee M. Cohen. Volume Editors: C. Steven Richards and Lee M. Cohen.
© 2021 John Wiley & Sons Ltd. Published 2021 by John Wiley & Sons Ltd.
236 Kelsey A. Maloney and Adam T. Schmidt

­ sychosocial milieu and a better understanding of mental health concerns that may exacerbate
p
the course of the presenting medical issue or, at the very least, complicate the treatment of this
condition. Efficient and thorough psychological assessment is a key portion of the role of
­psychology in a medical setting. In this chapter, our goal is to present a brief overview of the
specific roles for psychologists and of psychological assessment in particular within different
types of medical settings in which their expertise is routinely employed.

Primary Care Settings

“Primary Care Psychologists are experts in: (a) assessment & evaluation of common psycho-
social symptoms…[seen in primary care setting]; (b) [able to distinguish between symptoms
associated with a medical disease and a mental health condition]; (c) collaborate with primary
care teams; (d) have the knowledge to triage appropriately; (e) have an understanding of
biomedical conditions commonly seen in primary care and applicable pharmacological inter-
ventions (p. 8)” (Frank et al., 2004, in James, 2006). Primary care psychologists can be help-
ful in screening for common psychological conditions impacting certain age groups such as
autism and attention deficit hyperactivity disorder (ADHD) in pediatric settings or mild cog-
nitive impairment in older adults, common psychiatric symptoms including depression and
anxiety (Kush, 2001; Thombus et al., 2012), and screening for psychoactive substance use
(Kush, 2001).
Psychologists working with primary healthcare providers may be called on to facilitate
screening for disorders common in specific age groups. For example, a psychologist working
with a pediatrician may administer screening measures to assess for developmental disabilities
such as autism spectrum disorders in toddlers or ADHD in school‐aged children. These could
be direct administration of screening measures by the psychologist or, more commonly, con-
sultation and interpretation of instruments administered by the medical staff. A positive result
on one of these measures may trigger consultation with a psychologist to either perform a
more in‐depth assessment or to provide additional guidelines or context for the findings.
Similarly, physicians working with older adults may refer for additional assessment following a
physical exam in which a patient appears confused or somewhat disoriented. This model of
working with primary care providers can greatly facilitate the continuum of care and help to
ensure that individuals who may not otherwise be evaluated for these, relatively common,
disorders are able to be screened and, if necessary, assessed in a timely fashion.
Screening for depression can be another important role for psychologists working in
­primary care settings. Screening for depression includes “the use of questionnaires concern-
ing the symptoms of depression or small sets of questions about depression to identify
patients who may have depression but who have not sought treatment and whose depression
has not already been recognized by health care providers” (Thombus et al., 2012). Using
depression rating scales can help physicians identify depression, sometimes increasing their
ability to do so by 2.5‐ to 25‐fold (Kush, 2001). Certain medical illnesses have been associ-
ated with high risk for depression, including “seizure disorders, diabetes, hypothyroidism,
hyperthyroidism, Huntington’s disease, Parkinson’s disease, and cancer” (Kush, 2001).
Depression in these populations can complicate treatment and exacerbate the course of the
medical disorders. More general patient stressors such as disability resulting from the medi-
cal condition and/or significant psychosocial stressors (e.g., the loss of a job, grief from the
loss of a loved one, or stress resulting from rigorous treatment regimens) should also trigger
evaluations for depressive symptoms. A common and quick depression questionnaire that
 Psychological Assessment in Medical Settings: Overview and Practice Implications 237

can be used for screening in primary care settings is the Beck Depression Inventory, Second
Edition (BDI‐II) (Beck, Steer, & Brown, 1996). The BDI‐II is a 21‐item self‐report meas-
ure that can be completed in 5–10 min, can be scored rapidly, and can be used from age 13
to adulthood. Mean BDI‐II scores “have been established for Major Depression (single
episode, 28.065, recurrent 29.45), Dysthymic Disorder 24.02, Bipolar‐Depressed 20.59,
and Adjustment Disorder with Depressed Mood 17.29” (Kush, 2001). The BDI for Primary
Care (BDI‐PC) (Steer, Cavalieri, Leonard, & Beck, 1999), an abridged version, is also an
option in primary care settings (Kush, 2001).
Although advantages for screening for depression has potential value, “no trials have found
that patients who undergo screening have better outcomes than patients who do not when the
same treatments are available to both groups” (Thombus et al., 2012). Routine screening of
all patients for depression is labor intensive and can lead to misidentification of depression in
some individuals, resulting in treatment for depression in patients with subclinical or mild
symptoms and resources allocated away from patients who truly have depression (Thombus
et al., 2012). As an alternative to screening, the National Institute for Health and Clinical
Excellence 2010 guidelines recommend physicians be alert to possible depressive disorders,
especially when there is (a) a previous history of depression in the target patient, (b) when
patients have a chronic physical condition, and (c) when the patient has a new or worsening
physical impairment that causes functional limitations, and screen for depressive symptoms
when there is a specific concern such as the recent loss or change in the individual’s living situ-
ation, support network, or quality of life (Thombus et al., 2012).
Anxiety disorders have significant comorbidity with medical disorders including heart and
lung diseases, fibromyalgia, and diabetes (Kush, 2001). Screening for anxiety disorders in
primary care health settings is especially important in patients reporting somatic concerns
including shortness of breath and chest pains. If undertaken in an efficient manner so as to
not interfere with legitimate medical problems, screening can lead to reduced medical costs
and improved outcomes by helping physicians make differential diagnoses and guide the
selection of appropriate treatment (Kush, 2001). The Beck Anxiety Inventory (BAI) (Beck &
Steer, 1993) is a 21‐item self‐report measure that can be completed and scored quickly.
Fourteen items measure biological symptoms of anxiety, and seven items measure psychologi-
cal anxiety symptoms; no items specifically measure phobias or obsessions and compulsions
(Kush, 2001). Mean BAI norms have been established for “Panic Disorder with Agoraphobia
(M = 27.27, Panic Disorder without Agoraphobia (M = 28.81), Social Phobia (M = 17.77),
Obsessive‐Compulsive Disorder (M = 21.69), and [Generalized Anxiety Disorder]
(M = 18.83)” (Kush, 2001).
Another consideration for psychologists practicing in primary care settings where time and
resources are commodities is the significant comorbidity between anxiety and depression. In
settings where this is of concern, other measures that screen for both types of symptoms may
be most appropriate. The Hamilton Rating Scale for Depression (HAM‐D) (Hamilton, 1960)
is clinician administered and is used to screen for depression; it also contains three anxiety
items and can be used to assess a patient’s overlap in anxiety and depression symptoms. Both
the BDI‐II and BAI have shown discrimination between depression and anxiety (Kush, 2001).
In addition to internalizing concerns, drug and alcohol abuse are aspects of concern when
patients present to primary care settings. According to Kush (2001), approximately 10% of
adults experience significant dysfunction from alcohol or drug use at any time, yet most of
these adults can present to medical appointments without any outward presentation of their
substance use. Substance use and complications arising from this use can complicate the course
of chronic health conditions and can attenuate the effectiveness of medical interventions. As a
238 Kelsey A. Maloney and Adam T. Schmidt

result, psychologists need to incorporate screening measures of substance abuse in their

­standard assessment protocols for primary care patients. The Drug Abuse Screening Test
(DAST‐20) (Skinner, 1982) is a 20‐item assessment for drug abuse over 12 months, including
both prescription drug and illicit drug use, and it can be administered in approximately 5 min
via self‐report or interview (Kush, 2001). The Alcohol Dependence Scale (ADS) (Skinner &
Horn, 1984) is a 28‐item assessment for alcohol abuse over 12 months, and it can be admin-
istered in approximately 10 min via self‐report or interview (Kush, 2001). In cases of suspected
drug or alcohol abuse, it is important to establish a timeline of whether drug or alcohol use
preceded medical problems or vice versa as this distinction may have implications for etiology,
prognosis, and treatment.

Rehabilitation Settings

In addition to primary care settings, psychologists also frequently play a role in physical
­rehabilitation settings where patients present with a wide range of physical injuries/disabili-
ties and co‐occurring mental health concerns. Important components of psychological assess-
ment in rehabilitation settings include the measurement of social problem solving that may
impact treatment, functional impairments that may influence daily living, measures of disabil-
ity status, and coping skills/behavioral adjustment (Dreer et al., 2009; Hall, 1999).
Empirically supported measures of social problem solving include “the Means‐End Problem
Solving Procedure (MEPS; Platt & Spivack, 1975), the Problem Solving Inventory (PSI;
Heppner, 1988), and the Social Problem Solving Inventory‐Revised (SPSI‐R; D’Zurilla,
Nezu, & Maydeu‐Olivares, 2002)” (in Dreer et al., 2009). These and similar tools are helpful
adjuncts to treatment in rehabilitation because social problem skills can help those living with
chronic health conditions or disabilities cope with psychological distress (Dreer et al., 2009).
Functional assessment measures assess disability across domains including “self‐care, mobil-
ity, and, more variably, cognition, communication, and behavior” (Hall, 1999). Measures of
functional disability include the Functional Independence Measure (FIM), which measures
motor and cognitive functioning; the Functional Assessment Measure (FAM), which is an
addition to the FIM (known together as the FIM + FAM) and adds 12 items on cognitive,
behavioral, communication, and community function (Hall, 1999); and the Disability Rating
Scale (DRS; Rappaport, Hall, Hopkins, Belleza, & Cope, 1982). Other measures of func-
tional disability include length of inpatient stay, hospital or rehabilitation charges (excluding
physician fees), and the intensity and type of treatment (i.e., service utilization; Hall, 1999).
Finally, client satisfaction with services is an important target variable for ascertaining the
quality of outcomes (Hall, 1999). These measures can help psychologists understand the
limitations of their patients and provide a road map for cognitive behavioral interventions
targeting specific areas of concern. Moreover, using these screening instruments can augment
information gained from traditional psychological assessments by providing context as to the
physical and cognitive limitations, patients may face upon returning home or during their stay
at the facility.
Measures of disability status typically include analyses of community integration, service
utilization, and independence. The Community Integration Questionnaire (CIQ) (Willer,
Ottenbacher, & Coad, 1994) is a 15‐item self‐administered or interview‐based questionnaire
that assesses community integration for individuals with TBI across three dimensions: home
integration, social integration, and productivity (Hall, 1999). The Craig Handicap Assessment
and Reporting Technique (CHART) (Whiteneck, Charlifue, Gerhart, Overholser, &
 Psychological Assessment in Medical Settings: Overview and Practice Implications 239

Richardson, 1992) assesses five domains of “physical independence, mobility, occupation,

social integration, and economic self‐sufficiency” in individuals with spinal cord injury (Hall,
1999). Other measures of handicap status include employment, which can be measured by
the CIQ, CHART, FIM + FAM, DRS, or a monthly employment ratio; living arrangements,
which provides an estimation of an individual’s “level of dependence…and cost to society”;
and service utilization (Hall, 1999). Measures of handicap status are useful additions to
assessments of functional limitations as they illustrate a patient’s level of independence in the
community and the extent to which their functional impairments impact their occupational
and social functioning all of which may interact with mental health conditions and personality
characteristics.
It is also important to assess psychosocial and behavioral adjustment in patients in rehabilita-
tive settings (Hall, 1999). The Neurobehavioral Rating Scale (NRS) (Levin et al., 1987) is a
27‐item assessment of cognitive and emotional disturbances and has been “the scale of choice
for assessing behavioral changes following TBI in neurosurgical trials,” although it requires
substantial training, judgment, and “familiarity with the patient” to administer (Hall, 1999).
Additionally, quality of life should be assessed as it is “arguably an ultimate aim of rehabilita-
tion”; quality of life can be assessed using the Satisfaction with Life Scale (Diener, Emmons,
Larsen, & Griffin, 1985) or the Quality of Life Scale (Chubon, 1987, in Hall, 1999).

Specialty Settings

Cardiology
Anxiety and depression are the most prevalent classes of psychiatric disorders, and coronary
heart disease (CHD) is a highly prevalent cardiovascular issue in the general population.
Anxiety is an independent predictor of later CHD events and cardiac mortality, and depression
is associated with elevated risk of later cardiac episodes (Compare, Germani, Proietti, &
Janeway, 2011). “In 2008, the American Heart Association recommended [and the American
Psychiatric Association endorsed] that ‘screening tests for depressive symptoms should be
applied to identify cardiology patients who may require further assessment and treatment’ if
appropriate referral for further depression assessment and treatment is available” (Compare
et al., 2011). As patients who have anxiety or depression are at increased risk for cardiovascular
complications, it is important to assess patients with cardiovascular disease, in particular, for
emotional conditions that may compound their risk for adverse cardiovascular events (Compare
et al., 2011).
Although general measures of anxiety and depression mentioned previously (BDI, BAI,
Hamilton Anxiety Scale) can be used to assess these symptoms, there are several assessment
measures for anxiety and depression that were developed for specific use in cardiovascular
patient populations. The Diagnostic Interview with Structures Hamilton (DISH) (Freedland
et al., 2002) is used with patients with acute coronary syndrome as a measure conducive to
brief hospital visits, whereas the Maastricht Questionnaire (Appels, 1989) specifically assesses
exhaustion (Compare et al., 2011). If assessment identifies patients with moderate to severe
symptoms of anxiety or depression who have also either failed several trials of psychotropic
medication, who have a history of previous psychiatric diagnosis, and/or who possess any one
of a variety of risk factors (e.g., history of physical abuse or sexual victimization), the recom-
mendation would be for these individuals to receive a more thorough assessment (Compare
et al., 2011).
240 Kelsey A. Maloney and Adam T. Schmidt

Organ Transplantation
Patients on the wait list for or who have received a donor organ are vulnerable to a variety of
psychological issues. Adaptive and mental health challenges can occur at each stage of illness
and treatment, including “organ failure/chronic illness, pretransplant evaluation, waiting for
a donor, surgery, recovery, rehabilitation, [and] permanent maintenance (Olbrisch, Benedict,
Ashe, & Levenson, 2002).” The selection process to receive a donor organ includes a process
for determining a patient’s fitness to receive a donor organ such as psychological functioning
and determination of any contraindications to transplantation (Maldonado et al., 2012).
As the gap between organ donation and patients awaiting transplant increases, it is becom-
ing more important to identify potential risk factors (i.e., “substance abuse, compliance issues,
serious psychopathology”) that could result in greater risk of postoperative noncompliance
through the utilization of pretransplant psychological evaluations (Olbrisch et al., 2002).
Psychological evaluations also help “[promote] fairness and equal access to care, [provide] a
description of the patient’s neuropsychiatric and cognitive functioning, [serve] as a guide for
the clinical management of the patient and [address] the psychological needs of the transplant
team with regard to patient care” (Olbrisch et al., 2002). A typical pretransplant psychological
evaluation consists of a clinical interview on the patient’s background and functioning, the
possible use of standardized instruments, possible brief screenings for cognitive deficits such as
mental status evaluations or neuropsychological measures of memory and executive function-
ing, collateral information (especially in patients with substance abuse history), and assessing
for the quality of the patient’s support system (Olbrisch et al., 2002).
Standardized measures that can be used to assess patients as candidates for organ transplant
include the Psychosocial Assessment of Candidates for Transplantation (PACT) (Olbrisch,
Levenson, & Hamer, 1989), the Stanford Integrated Psychosocial Assessment for
Transplantation (SIPAT) (Maldonado et al., 2012), and the Readiness for Transition
Questionnaire (RTQ) (Gilleland, Amaral, Mee, & Blount, 2012) (Maldonado et al., 2012;
Marchak, Reed‐Knight, Amaral, Mee, & Blount, 2015; Olbrisch et al., 2002). The PACT
consists of eight items on a five‐point Likert scale and includes the rater’s impressions. The
SIPAT consists of 18 items across 4 domains: “Patient’s Readiness Level & Illness Management,
Social Support System Level of Readiness, Psychosocial Stability and Psychopathology, and
Lifestyle and Effect of Substance Use” (Maldonado et al., 2012). The RTQ consists of three
parallel versions—the RTQ‐Provider, RTQ‐Teen, and RTQ‐Parent—all designed to be
­completed by healthcare providers (Marchak et al., 2015).

Oncology
Cancer is a significant physical health ailment in modern society with approximately 14.5 ­million
people currently diagnosed with cancer in the United States (Stanton, Rowland, & Ganz,
2015). Diagnosis and treatment of cancer can cause significant psychological distress in
patients, including elevated symptoms of depression and anxiety that can affect more than one
in four patients with cancer (Stanton et al., 2015; Thalen‐Lindstrom, Larsson, Glimelius, &
Johansson, 2013). Stanton et al. (2015) proposed three periods during the survivorship
phase—reentry (completion of treatment to up to 1 year), early survivorship (approximately
5 years post‐diagnosis), and long‐term survivorship (beyond 5 years post‐diagnosis)—and
­proposed that psychological distress may be more pronounced in certain periods than in
­others. As a result, different assessment questions may predominate depending upon the stage
of treatment a patient is in.
 Psychological Assessment in Medical Settings: Overview and Practice Implications 241

For cancer patients, anxiety can center on a fear of cancer recurrence. Fear of recurrence is
common in long‐term survivors and can be triggered by “follow‐up medical visits, symptoms
that mimic illness (e.g., pain that may be attributed to disease spread), death of a public figure
from cancer, or a family member’s illness” (Stanton et al., 2015). Depression is also present in
cancer survivors, and there is a higher risk for depressive symptoms in those with advanced
cancer, receiving chemotherapy, and with more physical symptoms. However, it should be
noted that at 7 years after diagnosis, cancer survivors’ rates of depression are not significantly
different from healthy controls. Nonetheless, cancer treatments themselves can also result in a
number of cognitive effects including impairments in attention, working memory, concentra-
tion, and executive functioning (Stanton et al., 2015).
Similar to organ transplant assessment, assessment in oncology settings can help maximize
limited resources and identify patients in the most distress (Vodermaier, Linden, & Siu, 2009).
Brief, self‐report measures can be used to screen for oncology patients who are most in need
of psychological services, and systematic screening helps promote equal access to resources
better than physician‐ or patient‐initiated referrals, which can fail to identify emotionally
­distressed patients (Vodermaier et al., 2009). For a detailed review of ultrashort, short, and
long assessment measures that can be used as screeners for emotional distress in cancer patients,
see Vodermaier et al. (2009).
The Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983) is a
14‐item self‐report measure for anxiety and depression, with scores greater than 10 signifying
clinical cases of anxiety and depression. The HADS has been used as a screener for oncology
patients in clinical settings and does increase referral rates; those referred using the HADS,
however, had no difference in improvement from those in standard care (Thalen‐Lindstrom
et al., 2013).
Beyond anxiety and depression, cancer survivors are also likely to experience fatigue, cogni-
tive impairment, pain, and sexual and urinary/bowel problems, as well as difficulty with more
global issues such as finding benefits in their cancer experience and returning to work (Stanton
et al., 2015). Anxiety and depression symptoms can be risk factors for fatigue; other risk fac-
tors for fatigue include elevated body mass, catastrophic thinking, loneliness, and early life
adversity (Stanton et al., 2015). Cancer survivors often endorse problems in memory, atten-
tion, concentration, and executive function abilities; these problems can be exacerbated by risk
factors such as older age, lower education, or lower IQ (Stanton et al., 2015). Therefore, in
addition to psychosocial stressors and mental health symptoms, evaluations involving oncol-
ogy patients should also include screening measures for cognitive functioning in order to
determine if additional referrals for a comprehensive neuropsychological assessment is
appropriate.
Quality of life is also an important outcome to consider for cancer survivors. Quality of
life measures can include indicators of strength of interpersonal relationships and support
­systems, life appreciation, personal regard, and attention to health behaviors (Stanton et al.,
2015; Thalen‐Lindstrom et al., 2013). Although quality of life measurement is not t­ ypically
included in standard psychological assessments, it is understandable how these may facili-
tate treatment of cancer survivors or those patients dealing with continued cancer ­treatment.
An example measure for evaluating quality of life in oncology patients is the European
Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire
(QLQ‐C30) (Aaronson et al., 1993) that includes five functional scales (higher scores
reflect better ­ functioning), nine symptom scales (higher scores reflect more severe
­problems), and a global quality‐of‐life (QOL) scale (higher scores reflect better f­ unctioning;
Thalen‐Lindstrom et al., 2013).
242 Kelsey A. Maloney and Adam T. Schmidt

Conclusions

Having psychologists in medical care settings can provide useful insight into issues that arise
when there is comorbidity between medical and psychological disorders in medical health set-
tings. Psychological assessments can be used to screen for common psychological syndromes,
such as depression and anxiety, autism spectrum disorders, ADHD, and dementia, and to
evaluate conditions that may directly impact medical interventions such as substance abuse.
The role of psychology in specialty care settings is less focused on direct diagnosis of psycho-
logical disorders (although that may continue to be a focus of screening) but rather on issues
that are important for treatment and rehabilitation planning such as psychological distress,
contraindications of treatment, functional impairment, behavioral/social adjustment, and
coping skills. Psychological evaluations have already demonstrated usefulness in a variety of
medical settings, and their use and utility will likely increase as we continue to appreciate the
role of mental health in the etiology and maintenance of physical disease and the impact of
positive psychological adjustment on long‐term physical health and well‐being.

Author Biographies

Kelsey A. Maloney is a doctoral student in clinical psychology at Texas Tech University. She
received her MA from Sam Houston State University in 2016 and BS from Mississippi State
University in 2014. Her research interests include the intersection of health and forensic
­psychology, such as improving health outcomes in juvenile justice populations.
Adam T. Schmidt is an assistant professor of clinical psychology at Texas Tech University.
He received his PhD in psychology from the University of Minnesota. His research interests
are in the areas of psychological and neuropsychological assessment with at risk populations
and in using psychological assessment data to improve treatment outcomes.

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Suggested Reading
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Vodermaier, A., Linden, W., & Siu, C. (2009). Screening for emotional distress in cancer patients:
A systematic review of assessment instructions. Journal of the National Cancer Institute, 101(21),
1464–1488. doi:10.1093/jnci/djp336