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.

Ethical practice from the perspective of the forensic psychologist : commentary on the uses and value of the Australian Psychological Society (2007) code of ethics

Forensic practice in Australia and around the world attracts a high level of public and judicial scrutiny. The way in which the forensic psychologist conducts him or herself in ethically challenging situations is important not only to the reputation of the individual practitioner, but to the profession more widely. This paper outlines some of the ethical issues that commonly arise in forensic psychology practice and discusses these in relation to the recently published Australian Psychological Society (2007) Code of Ethics. Four ethically challenging scenarios are described and discussed in terms of how the Code might be used to offer guidance to psychologists about how they might best respond.

Assessing financial competence

Some people have cognitive impairments that may reduce their capacity to manage their own financial affairs. The legal decision to limit a person's right to manage his or her own finances depends, in part, on an assessment of financial competence. Currently, tribunals and courts may receive information from a variety of different sources (e.g., family members, general practitioner, psychologist, social worker etc.) and have to reconcile this information in order to make guardianship decisions. The first aim of this article is to critique contemporary methods, procedures and practices for assessing financial competence. The second aim is to suggest a standard assessment framework that could be employed by tribunals and courts to help them evaluate the status of a person's financial competence.

Cost-effectiveness of cognitive-behavioural therapy and drug interventions for major depression

Objective: Antidepressant drugs and cognitive–behavioural therapy (CBT) are effective treatment options for depression and are recommended by clinical practice guidelines. As part of the Assessing Cost-effectiveness – Mental Health project we evaluate the available evidence on costs and benefits of CBT and drugs in the episodic and maintenance treatment of major depression.

Method: The cost-effectiveness is modelled from a health-care perspective as the cost per disability-adjusted life year. Interventions are targeted at people with major depression who currently seek care but receive non-evidence based treatment. Uncertainty in model inputs is tested using Monte Carlo simulation methods.

Results: All interventions for major depression examined have a favourable incremental cost-effectiveness ratio under Australian health service conditions. Bibliotherapy, group CBT, individual CBT by a psychologist on a public salary and tricyclic antidepressants (TCAs) are very cost-effective treatment options falling below $A10 000 per disability-adjusted life year (DALY) even when taking the upper limit of the uncertainty interval into account. Maintenance treatment with selective serotonin re-uptake inhibitors (SSRIs) is the most expensive option (ranging from $A17 000 to $A20 000 per DALY) but still well below $A50 000, which is considered the affordable threshold.

Conclusions: A range of cost-effective interventions for episodes of major depression exists and is currently underutilized. Maintenance treatment strategies are required to significantly reduce the burden of depression, but the cost of long-term drug treatment for the large number of depressed people is high if SSRIs are the drug of choice. Key policy issues with regard to expanded provision of CBT concern the availability of suitably trained providers and the funding mechanisms for therapy in primary care.

Quandary 2003 -

Dr Marcia Devlin is an educational psychologist and Professor of Higher Education Research at Deakin University. Marcia has a broad and extensive publication record in the scholarship of teaching and learning that incorporates academic development, student learning support and the use of information and communication technologies in teaching and learning.  She writes regularly for The Age and Campus Review newspapers.

The Age (Education section) 2003 -

Dr Marcia Devlin is an educational psychologist and Professor of Higher Education Research at Deakin University. Marcia has a broad and extensive publication record in the scholarship of teaching and learning that incorporates academic development, student learning support and the use of information and communication technologies in teaching and learning. She writes regularly for The Age and Campus Review newspapers.

Treatment of depression in low-level residential care facilities for the elderly

Background: The rate of recognition and treatment of depressed older people in nursing homes is low. Data from the low-level residential care population have not been reported. This study aimed to collect information about the treatment of depression among older persons living in low-level residential care (hostels).

Method: The participants comprised 300 elderly residents from ten low-level residential care facilities from various suburbs in metropolitan Melbourne. The participants were interviewed by a trained clinical psychologist to determine the presence or absence of major or minor depressive disorder using the Structured Clinical Interview for DSM-IV Axis I Disorder (SCID-I). Each participant was also administered the Standardized Mini-mental State Examination (SMMSE) to determine level of cognitive function. The clinical psychologist then reviewed all cases in consultation with a geropsychiatrist experienced in the diagnosis of depression among older people, prior to assigning a diagnosis of depression.

Results: An important finding in this study was the low treatment for currently depressed residents, with less than half of those in the sample who were depressed receiving treatment. However, 61 of the 96 residents out of the sample of 300 who were on antidepressants were not currently depressed.

Conclusion: There is an under recognition and under treatment of currently depressed older people in low-level residential care facilities (hostels) just as has been reported in studies in nursing homes. However, there are high numbers receiving antidepressants who are not currently depressed.

Cost-effectiveness of psychological and pharmacological interventions for generalized anxiety disorder and panic disorder

Objective: To assess from a health sector perspective the incremental cost-effectiveness of interventions for generalized anxiety disorder (cognitive behavioural therapy [CBT] and serotonin and noradrenaline reuptake inhibitors [SNRIs]) and panic disorder (CBT, selective serotonin reuptake inhibitors [SSRIs] and tricyclic antidepressants [TCAs]).

Method: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analyses of randomised controlled trials. An assessment on second stage filters ('equity', 'strength of evidence', 'feasibility' and 'acceptability to stakeholders') is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are calculated for a period of one year for the eligible population (prevalent cases of generalized anxiety disorder/panic disorder identified in the National Survey of Mental Health and Wellbeing, extrapolated to the Australian population in the year 2000 for those aged 18 years and older). Simulation modelling techniques are used to present 95% uncertainty intervals (UI) around the incremental cost-effectiveness ratios (ICERs).

Results: Compared to current practice, CBT by a psychologist on a public salary is the most cost-effective intervention for both generalized anxiety disorder (A$6900/DALY saved; 95% UI A$4000 to A$12 000) and panic disorder (A$6800/DALY saved; 95% UI A$2900 to A$15 000). Cognitive behavioural therapy results in a greater total health benefit than the drug interventions for both anxiety disorders, although equity and feasibility concerns for CBT interventions are also greater.

Conclusions: Cognitive behavioural therapy is the most effective and cost-effective intervention for generalized anxiety disorder and panic disorder. However, its implementation would require policy change to enable more widespread access to a sufficient number of trained therapists for the treatment of anxiety disorders.

Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents

Objective:
To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to ‘current practice’.
Method:
The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria (‘equity’; ‘strength of evidence’, ‘feasibility’ and ‘acceptability to stakeholders’) is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6–17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios.
Results:
Compared to current practice, CBT by public psychologists is the most costeffective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders.
Conclusions:
Cognitive behavioural therapy provided by a public psychologist is the most
effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require ‘start-up’ costs and attention to ensuring an adequate workforce.

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.

Benchmarking the teaching of Australian Indigenous content in undergraduate psychology

This paper discusses a teaching and learning project on incorporating Australian Indigenous content into psychology undergraduate programs. After the impetus generated by the Head of Schools meeting in Perth in 1998 and the publication of the special issue of the Australian Psychologist on Psychology and Indigenous peoples in 2000, little progress seems to have been made. The paper discusses the process of developing curriculum guidelines for psychology academics wishing to include Indigenous content. These include the need to critically examine the assumptions and history of Western psychology in relation to Indigenous peoples, the inclusion of non-conventional teaching and learning methods, staff and institutional support, and appropriate staff development. While we have been encouraged by the growing support for this process, there are also significant obstacles, including rigidity of thinking about psychology programs and the attitude that it is all too hard. It is important to get this right, since the token inclusion of Indigenous material into otherwise mainstream Western psychology courses will be ineffective in bringing about the required understanding for psychology students wishing to work with Indigenous people in their professional careers and bring about social justice.

Beating the blues after cancer : randomised control trial of a tele-based psychological intervention for high distress patients and carers

Background : The diagnosis and treatment of cancer is a major life stress such that approximately 35% of patients experience persistent clinically significant distress and carers often experience even higher distress than patients. This paper presents the design of a two arm randomised controlled trial with patients and carers who have elevated psychological distress comparing minimal contact self management vs. an individualised tele-based cognitive behavioural intervention.

Methods/design : 140 patients and 140 carers per condition (560 participants in total) will been recruited after being identified as high distress through caller screening at two community-based cancer helplines and randomised to 1) a single 30-minute telephone support and education session with a nurse counsellor with self management materials 2) a tele-based psychologist delivered five session individualised cognitive behavioural intervention. Session components will include stress reduction, problem-solving, cognitive challenging and enhancing relationship support and will be delivered weekly. Participants will be assessed at baseline and 3, 6 and 12 months after recruitment. Outcome measures include: anxiety and depression, cancer specific distress, unmet psychological supportive care needs, positive adjustment, overall Quality of life.

Discussion : The study will provide recommendations about the efficacy and potential economic value of minimal contact self management vs. tele-based psychologist delivered cognitive behavioural intervention to facilitate better psychosocial adjustment and mental health for people with cancer and their carers.

Vision and rationalisation : a study of the school psychology profession within the Victorian Government school system

Since its origins in the 19th century, modern schooling has been a continuously contested domain within nation states. Underlying this contestation dynamic lie competing value systems about the social purpose of education; competing values around which are generated different discourses, and which in turn generate inherently contradictory social and organisational structures. As reflected in other areas of society, the 20th century expansion of state-provided schooling has essentially developed around variations of a bureaucratic model Thus, organisational cultures based around bureaucratic values have come to permeate the enterprise of schooling on a world wide scale. Concomitantly, the value for education to be fundamentally associated with human emancipation from psychological, social, political, or economic states of being, persists as a recurring theme in modern schooling. Premised on these understandings, the thesis argues that the development of the practices of school psychology as a profession, like education in general, and special education in particular, has similarly been influenced by tensions between different and competing constellations of values. It is argued that throughout the 20th century, the pervasiveness of formal schooling systems suggest that schooling may be understood as a modernist cultural archetype. As a socially constructed reality, the phenomenon of schooling has become unproblematic the apparent cultural inevitability of formal schooling in the modern era can also be understood as a premise of a systemised way of looking at the world; that of bureaucratic consciousness. Dialectically, bureaucratic consciousness persists in influencing every manifestation of schooling; structurally through its organisational forms, and epistemologically through the institutionalization of teaching and learning. A particular illustration of the dialectical relationship between bureaucratic consciousness and the social forms and social practices of schooling is the school psychology profession which has developed as a part of school systems. The thesis argues that the epistemic archeology of psychology as a knowledge discipline can be traced through an earlier European intellectual and cultural tradition, but in the 20th century, has come to develop a symbiotic yet contradictory relationship with compulsory schooling in the modern nation state. The research study employs historical and fieldwork methods in a study of the development of the school psychology services within the Victorian Education Department, particularly between 1947 and 1987. The thesis also draws upon several usually distinct literatures; the philosophical and theoretical discourse of modernity and post modernity, the history and development of modern schooling, the ethnography of schooling, the international comparative literature on the school psychology profession, and the literature on action research in education practice and curriculum development, As a case study of Victorian school psychology, the research eschews a quantitative statistical approach in favour of qualitative investigatory genres, which have in turn been guided by the values of action research in education, as well as those of critical theory. The important focus of the thesis is its investigation of some aspects of the development and transformations within the Victorian state education bureaucracy, and the dialectical relationship that has persisted between the evolution of change processes and the shifting conceptions of school psychology practices in the 20th century. A history of the organisational development of school psychology services in Victoria constitutes an important part of the thesis. This is complemented by specific illustrations of how some school psychologists have been influenced by and have contributed towards paradigm shifts within the profession, shifts relating to how the changing nature of their work practices have come to be understood and valued by teachers and by school administrators. The work of J. R. MacLeod from the 1950s is noted in this regard. Particular attention is also drawn to the dialectical relationship between bureaucratic consciousness and school psychology's professional orientation in the 1980s. As a means of providing field data to explore this relationship, ethnographic case studies with two school communities are included as part of the fieldwork of the thesis, and are based upon the author's own work in the mid 1980s. These case studies provide a basis for conceptually refraining the school psychologist's professional experience within schooling systems, and an opportunity to examine how competing value systems impact upon the work of the school psychologist. The thesis concludes with some observations about bureaucratic transformations within educational organisations, and about the future relationship of the school psychology profession with schooling systems, as framed by the theoretical parameters of the modernist /post modernist debate. The issue of competing value systems within the administration of public education is re-examined as is the value of promoting human empowerment in the ongoing work of the school psychologist. Finally, some scenario building with reference to the future of school psychology in Victoria in is undertaken.