Evaluation of outcome in child and adolescent mental health services: children with persistent conduct problems

This article focuses on the evaluation of outcome in child and adolescent mental health services. We examined the outcomes of 46 children with persistent conduct problems by gathering at baseline and six months information from multiple informants on multiple domains including the functioning of the child, risk factors, and parents’ and children’s perceptions of the treatment process. A statistically significant reduction in oppositional/conduct symptoms was reported six months after the initial clinical contact. However, the majority of the group still scored within the clinical range. The various outcome measures are correlated to only a mild to moderate degree. Teachers did not notice the same degree of change at school, despite the changes noticed by parents. Symptom improvement and satisfaction with a service are two separate issues. Parents’ satisfaction was related to their perception of the therapist and the therapy offered. Their satisfaction was high if they perceived that the therapist was able to communicate well, show care and concern, and if the therapy was perceived as organized. Much can be learned from a comprehensive outcome measurement system within a mental health service.

International standards of business conduct: framework and illustration

Purpose: – The purpose of this paper is to describe the insights and a proposal into the structure of standards of business conduct and its intended applications.

Design/methodology/approach: – The case study is based upon an inductive content analysis of corporate ethics artefacts.

Findings: – It is concluded that the standards of business conduct may be highly prescriptive in world wide corporations, but that there should be an explicit commitment to a flexible and dynamic approach to the application of standards of business conduct.

Research limitations/implications: – An examination of the actual behaviour of a corporation's operations was beyond the scope of the present research, but such a study has potential for future research. This would open up the wider question of how corporations can minimise the gap between corporate intentions and actual outcomes in business operations across national and cultural boundaries.

Practical implications: – These diverse national and cultural contexts that world wide corporations encounter must be taken into consideration in the content of their standards of business conduct.

Originality/value: – The authors emphasise the concern of recognising that the contexts surrounding standards of business conduct are dynamic. Corporate codes of ethics should be regarded as dynamic artefacts. A framework of application is proposed.

Human sympathetic nerve biology : parallel influences of stress and epigenetics in essential hypertension and panic disorder

Patients with panic disorder provide a clinical model of stress. On a "good day," free from a panic attack, they show persistent stress-related changes in sympathetic nerve biology, including abnormal sympathetic nerve single-fiber firing ("salvos" of multiple firing within a cardiac cycle) and release of epinephrine as a cotransmitter. The coreleased epinephrine perhaps originates from in situ synthesis by phenylethanolamine N-methyltransferase (PNMT). In searching for biological evidence that essential hypertension is caused by mental stress—a disputed proposition—we note parallels with panic disorder, which provides an explicit clinical model of stress: (1) There is clinical comorbidity; panic disorder prevalence is increased threefold in essential hypertension. (2) For both, epinephrine cotransmission is present in sympathetic nerves. (3) In panic disorder and essential hypertension, but not in health, single-fiber sympathetic nerve firing salvos occur. (4) Tissue nerve growth factor is increased in both conditions (nerve growth factor is a stress reactant). (5) There is induction of PNMT in sympathetic nerves. Essential hypertension exhibits a further manifestation of mental stress: there is activation of noradrenergic brain stem neurons projecting to the hypothalamus and amygdala. These pathophysiological findings strongly support the view that chronic mental stress is important in the pathogenesis of essential hypertension. A hypothesis now under test is whether in both disorders, under prevailing conditions of ongoing stress, PNMT induced in sympathetic nerves acts as a DNA methylase, causing the norepinephrine transporter (NET) gene silencing that is present in both conditions. PNMT can have an intranuclear distribution, binding to DNA. We have demonstrated that the reduced neuronal noradrenaline reuptake present in both disorders does have an epigenetic mechanism, with demonstrable reduction in the abundance of the transporter protein, the NET gene silencing being associated with DNA binding by the methylation-related inhibitory transcription factor MeCP2.

A controlled trial of internet-based cognitive-behavioural therapy for panic disorder with face-to-face support from a general practitioner or email support from a psychologist

Background: Panic disorder (PD) is one of the most common anxiety disorders seen in general practice, but provision of evidence-based cognitive-behavioural treatment (CBT) is rare. Many Australian GPs are now trained to deliver focused psychological strategies, but in practice this is time consuming and costly.

Objective: To evaluate the efficacy of an internet-based CBT intervention (Panic Online) for the treatment of PD supported by general practitioner (GP)-delivered therapeutic assistance.

Design: Panic Online supported by GP-delivered face-to-face therapy was compared to Panic Online supported by psychologist-delivered email therapy.

Methods: Sixty-five people with a primary diagnosis of PD (78% of whom also had agoraphobia) completed 12 weeks of therapy using Panic Online and therapeutic assistance with his/her GP (n = 34) or a clinical psychologist (n = 31). The mean duration of PD for participants allocated to these groups was 59 months and 58 months, respectively. Participants completed a clinical diagnostic interview delivered by a psychologist via telephone and questionnaires to assess panic-related symptoms, before and after treatment.

Results: The total attrition rate was 20%, with no group differences in attrition frequency. Both treatments led to significant improvements in panic attack frequency, depression, anxiety, stress, anxiety sensitivity and quality of life. There were no statistically significant differences in the two treatments on any of these measures, or in the frequency of participants with clinically significant PD at post assessment.

Conclusions: When provided with accessible online treatment protocols, GPs trained to deliver focused psychological strategies can achieve patient outcomes comparable to efficacious treatments delivered by clinical psychologists. The findings of this research provide a model for how GPs may be assisted to provide evidence-based mental healthcare successfully.

Therapist-assisted, internet-based treatment for panic disorder: can general practitioners achieve comparable patient outcomes to psychologists

Background: Mental illness is an escalating concern worldwide. The management of disorders such as anxiety and depression largely falls to family doctors or general practitioners (GPs). However, GPs are often too time constrained and may lack the necessary training to adequately manage the needs of such patients. Evidence-based Internet interventions represent a potentially valuable resource to reduce the burden of care and the cost of managing mental health disorders within primary care settings and, at the same time, improve patient outcomes.
Objective: The present study sought to extend the efficacy of a therapist-assisted Internet treatment program for panic disorder, Panic Online, by determining whether comparable outcomes could be achieved and maintained when Panic Online was supported by either GPs or psychologists.
Methods: Via a natural groups design, 96 people with a primary diagnosis of panic disorder (with or without agoraphobia) completed the Panic Online program over 12 weeks with the therapeutic assistance of their GP (n = 53), who had received specialist training in cognitive behavioral therapy, or a clinical psychologist (n = 43). Participants completed a clinical diagnostic telephone interview, conducted by a psychologist, and a set of online questionnaires to assess panic-related symptoms at three time periods (pretreatment, posttreatment, and 6 month follow-up).
Results: Both treatments led to clinically significant improvements on measures of panic and panic-related symptomatology from pretreatment to posttreatment. Both groups were shown to significantly improve over time. Improvements for both groups were maintained at follow-up; however, the groups did differ significantly on two quality of life domains: physical (F₁,₈₂ = 9.13, P = .00) and environmental (F₁,₈₂ = 4.41, P = .04). The attrition rate was significantly higher among those being treated by their GP (χ²₁ = 4.40, P = .02, N = 96).
Conclusions: This study provides evidence that Internet-based interventions are an effective adjunct to existing mental health care systems. Consequently, this may facilitate and enhance the delivery of evidence-based mental health treatments to increasingly large segments of the population via primary care systems and through suitably trained health professionals.

Is internet-based CBT for panic disorder and agoraphobia as effective as face-to-face CBT

This study compared Panic Online (PO), an internet-based CBT intervention, to best-practice face-to-face CBT for people with panic disorder with or without agoraphobia. Eighty-six people with a primary diagnosis of panic disorder were recruited from Victoria, Australia. Participants were randomly assigned to either PO (n = 46) or best practice face-to-face CBT (n = 40). Effects of the internet-based CBT program were found to be comparable to those of face-to-face CBT. Both interventions produced significant reductions in panic disorder and agoraphobia clinician severity ratings, self reported panic disorder severity and panic attack frequency, measures of depression, anxiety, stress and panic related cognitions, and displayed improvements in quality of life. Participants rated both treatment conditions as equally credible and satisfying. Participants in the face-to-face CBT treatment group cited higher enjoyment with communicating with their therapist. Consistent with this, therapists’ ratings for compliance to treatment and understanding of the CBT material was higher in the face-to-face CBT treatment group. PO required significantly less therapist time than the face-to-face CBT condition.

Professional attitudes towards deliberate self-harm in patients with borderline personality disorder

Objective: The aim of the present study was to assess the attitudes of mental health and emergency medicine clinicians towards patients diagnosed with borderline personality disorder. The clinician gender, primary occupation and service setting, level of university training and years of experience, frequency of clinical contact, and completion of specific training in borderline personality disorder were expected to influence the attitudes of health professionals towards working with borderline patients that engage in self-harm.

Method: A purpose-designed questionnaire and an assessment tool to quantify attitudinal levels were used to collect demographic information and assess the attitudes of 140 mental health and emergency medicine practitioners across two Australian health services and a New Zealand health service.

Results: Statistically and clinically significant differences were found between emergency medical staff and mental health clinicians in their attitudes towards working with borderline personality disorder. The strongest predictor of attitudes was whether the clinician worked in emergency medicine or mental health. This was followed by years of experience and specific training in personality disorders as significant predictors of attitudes to self-harm.

Conclusions: The implications of these findings for the professional training of clinicians in the management and treatment of borderline personality disorder patients are discussed.

Targeted clinical education for staff attitudes towards deliberate self-harm in borderline personality disorder : randomized controlled trial

Objective: The aim of the present study was to assess the impact of attending targeted clinical education on borderline personality disorder on the attitudes of health clinicians towards working with deliberate self-harm behaviours commonly exhibited by patients diagnosed with this complex disorder. Comparisons of clinicians across service settings, occupational fields, and other demographic areas were also made.

Method: A purpose-designed demographic questionnaire and the Attitudes Towards Deliberate Self-Harm Questionnaire were used to collect the demographic information and assess the attitudes of 99 mental health and emergency medicine practitioners across two Australian health services and a New Zealand health service, both before and after education attendance.

Results: Statistically significant improvements in attitude ratings were found for both emergency medicine clinicians and mental health clinicians in working with deliberate self-harm behaviours in borderline personality disorder, following attendance at the education program with a medium affect size (t(32)=−3.45, p=0.002, d=0.43 and t(65)=−5.12, p=0.000, d=0.42, respectively). Clinicians across occupational areas of nursing, allied health, and medical fields demonstrated equivocal levels of improvement in their attitude ratings.

Conclusions: Results are discussed in terms of the necessity of providing regular access to targeted clinical education for health professionals working with patients diagnosed with borderline personality disorder.

Diagnosing borderline personality disorder : examination of how clinical indicators are used by professionals in the health setting

This paper reviews the history of the recognition of borderline personality disorder as a clinical disorder, followed by a review of the contemporary practice of diagnosing borderline personality disorder in psychiatric settings. Many researchers have cautioned against the conflation of difficult patients with the diagnostic category of borderline personality disorder. The current study examines how clinical indicators used to screen for this complex disorder differ across service settings, professions, specialised training and years of clinical experience. A purpose-designed survey was administered to 108 mental and emergency medicine health practitioners across an Australian health service and a New Zealand health service to record the level of significance placed on different clinical indicators in the application of the diagnosis of borderline personality disorder. A heavy reliance was placed on observable behavioural symptoms, such as self-mutilation and impulsive behaviours that are self-damaging, in the screening of borderline personality disorder as a psychiatric diagnosis. Statistically significant differences were found between emergency medical staff and mental health clinicians in their use of diagnostic indicators of borderline personality disorder, χ²(4) = 17.248, p = .002. Implications of these findings for the screening, assessment and diagnosis of patients with borderline personality disorder are discussed.

Rogue men and predatory women : female fan's perception of Australian footballers' sexual conduct

The 2004 Australian Football League and National Rugby League seasons started amidst claims made by women about players behaving inappropriately towards them. A raft of allegations surfaced in the media, prompting nationwide debate on the issue of sportsmen and violence. While sport sociologists have made important inroads toward understanding sexual misconduct by male athletes, much of this research appears to focus on the socio-cultural factors informing the perpetrators' actions. This study takes a different approach, analysing the perspectives of female Australian rules football fans to consider gendered narratives of sexual misconduct. Our findings demonstrate that discourses of individualism, along with a mix of socio-cultural and biological arguments, are used by women to reconcile players' misconduct with continuing support of their sport.