Effects of severe depression on TOMM performance among disability-seeking outpatients

Archives of Clinical Neuropsychology 21 (2006) 161 165 Effects of severe depression on TOMM performance among disability-seeking outpatients Y. Tami Yanez, William Fremouw, Jennifer Tennant, Julia Strunk, Kayla Coker Department of Psychology, Life Sciences Building, West Virginia University, Morgantown, WV 26505-6040, USA Accepted 18 July 2005 Abstract The purpose of this study is to examine the effects of severe depression on the Test of Memory Malingering (TOMM). The present study examined whether 20 participants with high levels of depression, as measured by the Beck Depression Inventory 2nd Edition (BDI-II) and with current diagnoses of Major Depressive Disorder, would perform significantly worse on the TOMM than a control group. The results showed that the depressed and control groups did not have significant mean group differences on TOMM performance. Of the 20 depressed participants, only 2 on Trial 2 and 1 on the Retention Trial scored below the cutoff of 45, while none of the control participants performed in this range. The potential ameliorating effects of medications on the performance of the depressed group are discussed. The results indicate that the TOMM can be used with even severely depressed participants with only slight caution. 2005 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. Keywords: Malingering; Memory; Depression; TOMM 1. The effects of severe depression on TOMM performance among disability-seeking outpatients Between 15 and 17% of cases presented in forensic settings have been judged to involve malingering (Rogers, Sewell, & Goldstein, 1994). According to Rogers and Bender (2003), two potential areas for deception are psychotic symptoms and cognitive impairment. An increasing number of studies have focused on the feigning of cognitive impairment, for several reasons. Memory loss suffered from head injuries can result in monetary rewards for those involved in civil suits. Deficient memory or intellectual impairment can also lead to findings of incompetence to stand trial or reduced responsibility in criminal trials. Frequently, psychologists are asked to provide expert testimony regarding the validity of an individual s presentation of his or her cognitive abilities. Making this determination can be a difficult task; therefore, Rogers and Bender (2003) emphasize the need for specialized assessment instruments in the detection of malingered cognitive impairment. The Test of Memory Malingering (TOMM; Tombaugh, 1996), a forced choice visual recognition task used to detect malingered memory impairment, has garnered praise as a promising forensic instrument (Delain, Stafford, & Ben Porath, 2003; Heinze & Purisch, 2001). It is composed of fifty lined drawings presented in two Learning Trials Corresponding author. Tel.: +1 304 293 2001x31662; fax: +1 304 293 6606. E-mail address: william.fremouw@mail.wvu.edu (W. Fremouw). 0887-6177/$ see front matter 2005 National Academy of Neuropsychology. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.acn.2005.07.009

162 Y.T. Yanez et al. / Archives of Clinical Neuropsychology 21 (2006) 161 165 and a delayed Retention Trial. A cutoff score of less than 45 correct of 50 items on Trial 2 or the Retention Trial is indicative of suboptimal effort and potential malingering. Vallabhajosula and van Gorp (2001) concluded that the TOMM might meet the Daubert standards for admissibility in court with its positive predictive values (PPV) of 100% and negative predictive values (NPV) above 80%. However, they warn that caution is needed regarding use of the TOMM until additional validation studies are conducted with non-simulator populations with psychiatric disorders such as depression or dementia. In fact, Teichner and Wagner (2004) recently reported that the TOMM is not appropriate for patients with dementia. The potential impact of depression on general neurocognitive test performance, not tests of malingering, has been examined by Rohling, Green, Allen, and Iverson (2002) in a study of 420 compensation-seeking outpatients. The high depression group had a mean Beck Depression Inventory (BDI; Beck & Steer, 1993) score of 31.2, while the low depression group had a mean BDI of 5.9. Unexpectedly, depression did not impact objective neurocognitive functioning; although, the depressed group subjectively reported more cognitive impairment. To specifically assess the potential impact of depression on the TOMM, Rees, Tombaugh, and Boulay (2001) compared the TOMM performance of 26 psychiatric inpatients diagnosed with an affective disorder who were divided into three levels of depression severity. Based on BDI scores, 12 were classified as severely depressed (BDI = 30 51), 8 were moderately depressed (BDI = 17 29), and 6 were minimally depressed (BDI = 3 16). There were no differences in TOMM performance across levels of depression, and no one scored below the cutoff of 45 on Trial 2 and Retention. While encouraging, the results from this small sample of clinically depressed inpatients, i.e., only 12 were severely depressed, warrants further replication by other researchers before concluding that the TOMM is not affected by depression or other psychiatric conditions. Furthermore, Christensen, Griffiths, MacKinnon, and Jacomb (1997) have cautioned researchers about potential confounds when studying the performance of depressed inpatients on neurocognitive measures. Recently, Ashendorf, Constantinou, and McCaffrey (2004) examined archival data from 197 community dwelling older adults ages 55 75 (M = 64.5) to determine if either depression or anxiety decreased TOMM performance. The BDI and STAI (State-Trait Anxiety Inventory; Spielberger, 1983) were used to assess depression and anxiety, respectively. The authors found that none of the subjects scored below the TOMM cutoff of 45, regardless of degree of depression or anxiety. However, the 31 participants who formed the depressed group only had a BDI mean score of 12.9 (S.D. = 3.1) with a range of 10 24. This depression group was primarily in the mild range with none in the severe range. Therefore, the impact of high levels of depression on TOMM performance among outpatients has not yet been examined. The present study used a severely depressed outpatient group to further examine the findings of Rees, Tombaugh, and Boulay (2001) and the results from the mildly depressed older community sample reported by Ashendorf, Constantinou, and McCaffrey (2004) that depression does not affect TOMM performance. The severely depressed group in the current study is a community sample applying for Social Security Disability benefits. They have a diagnosis of Major Depressive Disorder, scoring in the severe range on the Beck Depression Inventory 2nd Edition (BDI-II; 30 63). Contrary to the previous studies, it was predicted that the severely depressed group would perform significantly worse on the TOMM compared to a non-depressed control group because of the problems of diminished ability to concentrate associated with high levels of depression. If true, some depressed people may fail the TOMM and be incorrectly suspected of suboptimal effort because of this psychiatric problem. 2. Method 2.1. Participants 2.1.1. Clinical Group The depressed clinical sample consisted of 20 participants (7 male and 13 female) ranging in age from 22 to 52 years (M = 39.05, S.D. = 8.88). The level of education ranged from 8 to 14 years (M = 11.15, S.D. = 1.57), and 6 were married. All subjects in the clinical sample were recruited from an outpatient clinician s office after finishing a Social Security Disability evaluation. The second author invited 23 individuals to participate in a 30-min IRB, Universitysponsored study to earn US$ 5.00. They were informed that participation in this study was completely unrelated to the already completed disability evaluation and that its purpose was to examine the potential effects of depressed mood on memory tasks. Of the 20 who agreed to participate, 19 were taking anti-depressant medication, 13 had been previously hospitalized for depression, and all had a current diagnosis of Major Depressive Disorder from a mental health clinic

Y.T. Yanez et al. / Archives of Clinical Neuropsychology 21 (2006) 161 165 163 or psychiatric hospital based on medical records submitted with their disability application. A BDI-II score of 30 or higher was required for inclusion in the severely depressed group. The mean BDI-II score was 43.20 (S.D. = 6.98). 2.1.2. Control Group The control group consisted of 20 non-depressed participants recruited by the second author from the friends and family of the clinical group in the waiting room. They completed the BDI-II and were also paid US$ 5.00. The subjects (8 male and 12 female) ranged in age from 23 to 59 years (M = 41.65, S.D. = 10.79). The level of education ranged from 7 to 18 years (M = 13.3, S.D. = 2.79), and 14 were married. None were taking psychotropic medications nor in current psychiatric care. A BDI-II score of 20 or lower was required for inclusion in the control group of this study. The mean BDI-II score was 4.25 (S.D. = 4.42). 3. Materials The following tests were given according to their published directions. Beck Depression Inventory, 2nd Edition (Beck, Steer, & Brown, 1996). The BDI-II is a 21-item, self-report questionnaire measuring mood, affect, and physical activity over the past 2 weeks. The BDI-II was administered as a screening instrument prior to administration of the memory tests to determine level of depression and subsequent placement into clinical or control group. Test of Memory Malingering (Tombaugh, 1996). The TOMM contains two Learning Trials and one Retention Trial, each consisting of 50 black-and-white pictures. The Learning Trial begins with showing each of the 50 pictures for 3 s, with a 1-s rest interval, and the recognition phase consists of viewing 50 pairs of pictures (one previously shown and one distraction) and requires the individual to identify the previously shown picture. During the second learning trial, this process is repeated with the same 50 pictures in a different order. The 10-min delayed Retention Trial consists of only the Learning phase. A score of 45 or less in the second Learning Trial and the Retention Trial is recommended as a cutoff score to determine those putting forth less than desirable effort. The following tests were administered as filler tasks during the 10 min delay between Trial 2 and the Retention task: the 21-Item Test (Iverson & Franzen, 1993) and the Logical Memory subscale of the Wechsler Memory Scale, 3rd Edition (WMS-III; Wechsler, 1997). 3.1. Procedure The memory tests were administered by trained clinical psychology doctoral students or trained undergraduate psychology majors in the following order: TOMM (Trial 1, Trial 2), Logical Memory subscale of the WMS-III, the 21- Item Test, and the TOMM Retention Trial. The administrators did not know whether the participants were in the clinical or control group. Prior to being administered the tests, a consent form was reviewed and signed by each participant. Participants were also advised that their participation was voluntary and could not affect the previously completed disability evaluation. After administration of the tests, the participants were paid US$ 5.00 for their participation. 4. Results Frequency distributions and mean TOMM scores for each group are presented in Table 1. An analysis of variance (ANOVA) was conducted to test for differences between the groups. On TOMM Trial 1, the depressed group s scores (M = 44.5, S.D. = 6.6) were lower than the control group s scores (M = 47.8, S.D. = 3.2) but not significantly different, F (1, 38) = 3.95, p <.06. On TOMM Trial 2 and the Retention task there were also no significant differences. An inspection of the frequency distributions reveals that none of the control group scored below the cutoff score of 45 on Trial 2 or the Retention task, while in the depressed group only two participants in Trial 2 and one in the Retention task scored below 45. 5. Discussion The present study examined the effects of severe levels of depression on TOMM performance. Consistent with previous results (Ashendorf, Constantinou, & McCaffrey, 2004; Rees, Tombaugh, & Boulay, 2001), depression did not produce significantly different group means nor lower performance on the TOMM when using the recommended cutoff

164 Y.T. Yanez et al. / Archives of Clinical Neuropsychology 21 (2006) 161 165 Table 1 Frequency distributions and mean (S.D.) scores for the depressed and control groups TOMM trials Depressed Control Trial 1 50 49 5 12 48 47 7 4 46 45 2 1 <45 6 3 Mean (S.D.) 44.5 (6.6) 47.8 (3.2) Trial 2 50 49 16 19 48 47 1 0 46 45 1 1 <45 2 0 Mean (S.D.) 48.0 (4.9) 49.8 (.9) Retention 50 49 17 18 48 47 2 2 46 45 0 0 <45 1 0 Mean (S.D.) 48.6 (4.2) 49.8 (.6) score of below 45 on Trial 2 and the Retention task. Based on one study, dementia may interfere with performance on the TOMM (Teichner & Wagner, 2004) and the potential impact of mental retardation on TOMM performance has not been fully examined (Rogers & Bender, 2003). The present study has several limitations, including the relatively small sample size of 20 for the depression and control groups and the use of the BDI-II measure of depression due to its lack of validity scales. However, this depression measure was also used in the two previous studies, and the sample size is comparable to that used by Rees, Tombaugh, and Boulay (2001). Although the BDI-II does not have validity scales and may have been elevated by the disabilityseeking participants, all 20 participants had a documented current diagnosis of Major Depressive Disorder from a mental health facility, and 19 of 20 were taking SSRI medications. The impact of the SSRI medications, however, may have lessened the severity of the depressive symptoms, such as diminished ability to concentrate, that are often present when a person with Major Depressive Disorder without medications presents for an intake or an evaluation. A future study could compare the TOMM performance of medicated to non-medicated depressed participants before finally concluding the TOMM is not impacted by depression. At the present time, this is the third study that indicates TOMM performance is not significantly impacted by symptoms of depression. Therefore, the TOMM can be used in studies of participants with depression and in clinical settings when concerns arise regarding possible memory deficits. References Ashendorf, L., Constantinou, M., & McCaffrey, R. J. (2004). The effect of depression and anxiety on the TOMM in community-dwelling older adults. Archives of Clinical Neuropsychology, 19, 125 130. Beck, A.T., Steer, R.A. (1993). Beck Depression Inventory. San Antonia, TX: The Psychological Corporation. Beck, A., Steer, R., & Brown, G. (1996). Manual for Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation. Christensen, H., Griffiths, K., MacKinnon, A., & Jacomb, P. (1997). A quantitative review of cognitive deficits in depression and Alzheimer-type dementia. Journal of the International Neuropsychological Society, 3, 631 651. Delain, S. L., Stafford, K. P., & Ben-Porath, Y. S. (2003). Use of the TOMM in a criminal court forensic assessment setting. Assessment, 10(4), 370 381. Heinze, M. C., & Purisch, A. D. (2001). Beneath the mask: Use of psychological tests to detect and subtype malingering in criminal defendents. Journal of Forensic Psychology Practice, 1(4), 23 51. Iverson, G. L., & Franzen, M. D. (1993). A brief assessment instrument designed to detect malingered memory deficits. The Behavior Therapist, 134 135. Rees, L. M., Tombaugh, T. N., & Boulay, L. (2001). Depression and the Test of Memory Malingering. Archives of Clinical Neuropsychology, 16, 501 506.

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