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Telephone administration of neuropsychological tests can facilitate studies in schizophrenia
Schizophrenia Research 71 (2004) 505 – 506 www.elsevier.com/locate/schres
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Telephone administration of neuropsychological tests can facilitate studies in schizophrenia Stefanie Berns *, Sara Davis-Conway, Judith Jaeger North Shore Long Island Jewish Health System, Center for Neuropsychiatric Outcome and Rehabilitation Research, Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA Received 26 March 2004; received in revised form 29 March 2004; accepted 31 March 2004 Available online 19 June 2004
Compelling findings of neuropsychological (NP) correlates of functional disability in schizophrenia has led to the increased use of NP assessment in studies of longitudinal course, outcome, and intervention efficacy. However, these studies are impeded by the fact that standardized NP tests must be administered in-person, which can be expensive and burdensome to participants. This leads to sampling bias due to individuals discontinuing participation because they are unwilling or unable to travel to the testing site (Harrison et al., 1994). Also, researchers may choose to use samples of convenience or fewer follow-up assessments, restricting the generalizability of study results. Telephone testing has been shown to be reliable in healthy elderly and Alzheimers (reviewed by Ball and McLaren, 1997), healthy adolescents (Kent and Plomin, 1987), and chronic fatigue syndrome samples (McCue et al., 2002). However, it has not been studied in schizophrenia. For our pilot study, we recruited schizophrenia outpatients already enrolled in an ongoing NIMH-funded longitudinal study (PI: Jaeger 1R01MH55585) exam-
* Corresponding author. Tel.: +1-718-470-8436; fax: +1-718347-4759. E-mail address: [email protected] (S. Berns). 0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2004.03.023
ining NP deficits and life functioning. Forty-four consented to participate in this supplemental study (mean age = 37.2 years (S.D. = 8.8); mean age of illness onset = 19.0 (S.D. = 6.3); mean years of education = 12.2 (S.D. = 2.1); 45% = female; ethnic distribution = 45% Caucasian, 32% African American, 16% Hispanic, 7% Other; SCID-DSM-IV diagnoses = 45% paranoid, 5% undifferentiated, 50% schizoaffective). The test battery (measures of immediate attention, working memory, verbal memory, conceptual ability, and phonemic fluency) was administered in-person and by telephone (order counterbalanced). To prevent practice effects, the test –retest interval was at least 2 weeks (mean 38.6 days, S.D. = 15.5) and alternate versions of the tests were administered (order counterbalanced). To minimize outside factors that could affect performance during telephone testing, participants were instructed not to write anything down and to eliminate/minimize possible distractions, (e.g., shutting off radio). After telephone testing, participants were asked what strategies they used to perform the assessments (to help identify ‘‘cheating’’), and the examiner rated the level of distraction during testing. A one-way analysis of variance revealed no difference in test performance between participants with few or many distractions and those with no distractions during telephone testing. Hierarchical Linear Mo del
506
S. Berns et al. / Schizophrenia Research 71 (2004) 505–506
Table 1 Results of NP test performance by administration method NP test Wechsler Memory Scale-Revised (WMS-R) Digits Forward (Wechsler, 1987) WMS-R Digits Backward Letter Number Span (Gold et al., 1997) Controlled Oral Word Association Test (COWAT) (Benton and Hamsher, 1978) California Verbal Learning Test (CVLT) Trials 1 – 5 (Delis et al., 1987) CVLT Trial 1 CVLT Trial 5 CVLT List B CVLT Short Delay Cued Recall a
In-person
6.8 (2.2)
7.4 (2.3)
F(1,39.8) = 10.4, p = 0.00*
0.51
4.9 (2.0) 10.9 (4.0) 31.9 (10.6)
5.3 (2.1) 11.1 (3.9) 34.7 (12.3)
F(1,40.9) = 1.6, p = 0.21 F(1,38.5) = 0.1, p = 0.72 F(1,40.3) = 4.6, p = 0.04*
0.34
34.6 (10.1)
38.6 (12.1)
F(1,40.7) = 7.1, p = 0.01*
0.42
F(1,40.6) = 10.2, p = 0.00* F(1,41.0) = 3.9, p = 0.06 F(1,41.7) = 5.9, p = 0.02* F(1,41.3) = 1.9, p = 0.17
0.50
4.0 8.5 3.6 6.7
(1.6) (2.9) (1.6) (3.0)
4.8 9.5 4.4 7.3
(1.9) (3.3) (1.9) (3.5)
Statistic
Effect sizea (Cohen’s D)
Telephone
0.38
Effect sizes of phone vs. in-person NP administration all fell in the moderate range.
Analysis examined differences in test performance as a function of administration order (which setting was first: in-person vs. telephone), test form (original vs. alternate), and administration method (in-person vs. telephone). No differences were found for order of administration, and one significant difference for test form (CVLT List B, F(1,50.5) = 5.6, p = 0.02) was found. Table 1 displays differences between administration methods. Performance was equivalent on tasks that are demanding from the start yet conceptually simple (e.g., LNS/Digits Backward) and for conceptually demanding tasks that give the participant an opportunity to acclimate to task demands (e.g., CVLT Trial 5/Cued Recall). Conceptually complex tasks requiring immediate engagement at the outset were performed significantly more poorly by telephone than in-person (e.g., CVLT Trial 1/List B). Initial acquisition seems delayed when stimuli are presented by telephone, but recall of acquired information is equivalent. Perhaps lack of visual feedback from the test administrator delays the participant’s ability to engage in conceptually demanding tasks. Future studies should account for variability between test administrations that could be due to fluctuations in clinical state, more carefully control the test –retest interval, and also include a control group tested twice in-person over a comparable interval to determine the extent to which variability in NP test performance is due to normal change over time. While mixed, results suggest that telephone testing has promise for selected NP tests. Given the potential benefits (to cost, sampling bias, cognitive tracking)
afforded by telephone testing, a more comprehensive investigation examining viability in this population is warranted. Acknowledgements This was supported by NIMH R01MH55585 (Dr. Jaeger). The authors acknowledge the valuable assistance of Sarah Uzelac, PhD candidate, and Dr. Pa´l Czobor. References Ball, C., McLaren, P., 1997. The tele-assessment of cognitive state: a review. J. Telemed. Telecare 3, 126 – 131. Benton, A., Hamsher, K., 1978. Multiphasic Aphasia Examination Manual. University Of Iowa, Iowa City. Delis, D.C., Kramer, J.H., Kaplan, E., Ober, B.A., 1987. The California Verbal Learning Test. Psychological Corporation, New York. Gold, J.M., Carpenter, C., Randolph, C., Goldberg, T.E., Weinberger, D.R., 1997. Auditory working memory and Wisconsin Card Sorting Test performance in schizophrenia. Arch. Gen. Psychiatry 54, 159 – 165. Harrison, G., Mason, P., Glazebrook, C., Medley, I., Croudace, T., Docherty, S., 1994. Residence of incident cohort of psychotic patients after 13 years of follow up. British Medical Journal 308, 813 – 816. Kent, J., Plomin, R., 1987. Testing specific cognitive abilities by telephone and mail. Intelligence 11, 391 – 400. McCue, P., Scholey, A.B., Herman, C., Wesnes, K.A., 2002. Validation of a telephone cognitive assessment test battery for use in chronic fatigue syndrome. J. Telemed. Telecare 8, 337 – 343. Wechsler, D., 1987. Wechsler Memory Scale-Revised. Psychological Corporation, New York.
Short communication
Telephone administration of neuropsychological tests can facilitate studies in schizophrenia Stefanie Berns *, Sara Davis-Conway, Judith Jaeger North Shore Long Island Jewish Health System, Center for Neuropsychiatric Outcome and Rehabilitation Research, Zucker Hillside Hospital, 75-59 263rd Street, Glen Oaks, NY 11004, USA Received 26 March 2004; received in revised form 29 March 2004; accepted 31 March 2004 Available online 19 June 2004
Compelling findings of neuropsychological (NP) correlates of functional disability in schizophrenia has led to the increased use of NP assessment in studies of longitudinal course, outcome, and intervention efficacy. However, these studies are impeded by the fact that standardized NP tests must be administered in-person, which can be expensive and burdensome to participants. This leads to sampling bias due to individuals discontinuing participation because they are unwilling or unable to travel to the testing site (Harrison et al., 1994). Also, researchers may choose to use samples of convenience or fewer follow-up assessments, restricting the generalizability of study results. Telephone testing has been shown to be reliable in healthy elderly and Alzheimers (reviewed by Ball and McLaren, 1997), healthy adolescents (Kent and Plomin, 1987), and chronic fatigue syndrome samples (McCue et al., 2002). However, it has not been studied in schizophrenia. For our pilot study, we recruited schizophrenia outpatients already enrolled in an ongoing NIMH-funded longitudinal study (PI: Jaeger 1R01MH55585) exam-
* Corresponding author. Tel.: +1-718-470-8436; fax: +1-718347-4759. E-mail address: [email protected] (S. Berns). 0920-9964/$ - see front matter D 2004 Elsevier B.V. All rights reserved. doi:10.1016/j.schres.2004.03.023
ining NP deficits and life functioning. Forty-four consented to participate in this supplemental study (mean age = 37.2 years (S.D. = 8.8); mean age of illness onset = 19.0 (S.D. = 6.3); mean years of education = 12.2 (S.D. = 2.1); 45% = female; ethnic distribution = 45% Caucasian, 32% African American, 16% Hispanic, 7% Other; SCID-DSM-IV diagnoses = 45% paranoid, 5% undifferentiated, 50% schizoaffective). The test battery (measures of immediate attention, working memory, verbal memory, conceptual ability, and phonemic fluency) was administered in-person and by telephone (order counterbalanced). To prevent practice effects, the test –retest interval was at least 2 weeks (mean 38.6 days, S.D. = 15.5) and alternate versions of the tests were administered (order counterbalanced). To minimize outside factors that could affect performance during telephone testing, participants were instructed not to write anything down and to eliminate/minimize possible distractions, (e.g., shutting off radio). After telephone testing, participants were asked what strategies they used to perform the assessments (to help identify ‘‘cheating’’), and the examiner rated the level of distraction during testing. A one-way analysis of variance revealed no difference in test performance between participants with few or many distractions and those with no distractions during telephone testing. Hierarchical Linear Mo del
506
S. Berns et al. / Schizophrenia Research 71 (2004) 505–506
Table 1 Results of NP test performance by administration method NP test Wechsler Memory Scale-Revised (WMS-R) Digits Forward (Wechsler, 1987) WMS-R Digits Backward Letter Number Span (Gold et al., 1997) Controlled Oral Word Association Test (COWAT) (Benton and Hamsher, 1978) California Verbal Learning Test (CVLT) Trials 1 – 5 (Delis et al., 1987) CVLT Trial 1 CVLT Trial 5 CVLT List B CVLT Short Delay Cued Recall a
In-person
6.8 (2.2)
7.4 (2.3)
F(1,39.8) = 10.4, p = 0.00*
0.51
4.9 (2.0) 10.9 (4.0) 31.9 (10.6)
5.3 (2.1) 11.1 (3.9) 34.7 (12.3)
F(1,40.9) = 1.6, p = 0.21 F(1,38.5) = 0.1, p = 0.72 F(1,40.3) = 4.6, p = 0.04*
0.34
34.6 (10.1)
38.6 (12.1)
F(1,40.7) = 7.1, p = 0.01*
0.42
F(1,40.6) = 10.2, p = 0.00* F(1,41.0) = 3.9, p = 0.06 F(1,41.7) = 5.9, p = 0.02* F(1,41.3) = 1.9, p = 0.17
0.50
4.0 8.5 3.6 6.7
(1.6) (2.9) (1.6) (3.0)
4.8 9.5 4.4 7.3
(1.9) (3.3) (1.9) (3.5)
Statistic
Effect sizea (Cohen’s D)
Telephone
0.38
Effect sizes of phone vs. in-person NP administration all fell in the moderate range.
Analysis examined differences in test performance as a function of administration order (which setting was first: in-person vs. telephone), test form (original vs. alternate), and administration method (in-person vs. telephone). No differences were found for order of administration, and one significant difference for test form (CVLT List B, F(1,50.5) = 5.6, p = 0.02) was found. Table 1 displays differences between administration methods. Performance was equivalent on tasks that are demanding from the start yet conceptually simple (e.g., LNS/Digits Backward) and for conceptually demanding tasks that give the participant an opportunity to acclimate to task demands (e.g., CVLT Trial 5/Cued Recall). Conceptually complex tasks requiring immediate engagement at the outset were performed significantly more poorly by telephone than in-person (e.g., CVLT Trial 1/List B). Initial acquisition seems delayed when stimuli are presented by telephone, but recall of acquired information is equivalent. Perhaps lack of visual feedback from the test administrator delays the participant’s ability to engage in conceptually demanding tasks. Future studies should account for variability between test administrations that could be due to fluctuations in clinical state, more carefully control the test –retest interval, and also include a control group tested twice in-person over a comparable interval to determine the extent to which variability in NP test performance is due to normal change over time. While mixed, results suggest that telephone testing has promise for selected NP tests. Given the potential benefits (to cost, sampling bias, cognitive tracking)
afforded by telephone testing, a more comprehensive investigation examining viability in this population is warranted. Acknowledgements This was supported by NIMH R01MH55585 (Dr. Jaeger). The authors acknowledge the valuable assistance of Sarah Uzelac, PhD candidate, and Dr. Pa´l Czobor. References Ball, C., McLaren, P., 1997. The tele-assessment of cognitive state: a review. J. Telemed. Telecare 3, 126 – 131. Benton, A., Hamsher, K., 1978. Multiphasic Aphasia Examination Manual. University Of Iowa, Iowa City. Delis, D.C., Kramer, J.H., Kaplan, E., Ober, B.A., 1987. The California Verbal Learning Test. Psychological Corporation, New York. Gold, J.M., Carpenter, C., Randolph, C., Goldberg, T.E., Weinberger, D.R., 1997. Auditory working memory and Wisconsin Card Sorting Test performance in schizophrenia. Arch. Gen. Psychiatry 54, 159 – 165. Harrison, G., Mason, P., Glazebrook, C., Medley, I., Croudace, T., Docherty, S., 1994. Residence of incident cohort of psychotic patients after 13 years of follow up. British Medical Journal 308, 813 – 816. Kent, J., Plomin, R., 1987. Testing specific cognitive abilities by telephone and mail. Intelligence 11, 391 – 400. McCue, P., Scholey, A.B., Herman, C., Wesnes, K.A., 2002. Validation of a telephone cognitive assessment test battery for use in chronic fatigue syndrome. J. Telemed. Telecare 8, 337 – 343. Wechsler, D., 1987. Wechsler Memory Scale-Revised. Psychological Corporation, New York.