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.

Preventing the onset of depressive disorders : a meta-analytic review of psychological interventions

OBJECTIVE: A growing number of studies have tested the efficacy of preventive interventions in reducing the incidence of depressive disorders. Until now, no meta-analysis has integrated the results of these studies. METHOD: The authors conducted a meta-analysis. After a comprehensive literature search, 19 studies were identified that met inclusion criteria. The studies had to be randomized controlled studies in which the incidence of depressive disorders (based on diagnostic criteria) in an experimental group could be compared with that of a control group. RESULTS: The mean incidence rate ratio was 0.78, indicating a reduction of the incidence of depressive disorders by 22% in experimental compared with control groups. Heterogeneity was low to moderate (I²=33%). The number needed to treat to prevent one case of depressive disorder was 22. Moderator analyses revealed no systematic differences between target populations or types of prevention (universal, selective, or indicated). The data included indications that prevention based on interpersonal psychotherapy may be more effective than prevention based on cognitive-behavioral therapy. CONCLUSIONS: Prevention of new cases of depressive disorders does seem to be possible. Prevention may become an important way, in addition to treatment, to reduce the enormous public health burden of depression in the coming years.

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.

The development of CBT programmes for anger : the role of interventions to promote perspective-taking skills

Although the emotion of anger has, in recent years, been the subject of increasing theoretical analysis, there are relatively few accounts of how interventions designed to reduce problematic anger might be related to cognitively oriented theories of emotion. In this review of the literature we describe how a cognitive-behavioural approach to the treatment of those with anger-related problems might be understood in relation to conceptualizations of anger from a cognitive perspective. Three additional interventions (visual feedback, chair-work, forgiveness therapy) are identified that aim to improve the perspective-taking skills of angry clients. It is concluded that such interventions might be considered for use within the context of cognitive-behavioural treatment.

Readiness for anger management : clinical and theoretical issues

Anger management methods are a common and successful feature of contemporary cognitive behavioral therapy. Meta-analyses and narrative reviews of the outcome of anger management have been broadly supportive of the view that it is an effective approach. We argue in this paper that an important impediment to the future success of anger management is the failure to fully address the issue of treatment readiness. We discuss distinctive features of anger that make readiness a more important issue than it is for other problem emotions and affects. Relevant theoretical models of readiness are discussed and we review the components of a lack of readiness, including difficulties in establishing a therapeutic alliance. Progress in this area requires greater attention to the measurement and analysis of readiness, to its inclusion as an independent variable in outcome studies and to its clinical modification when readiness is low.

Evaluation of Bayesian belief networks for diagnosis of psychotic disorders

The thesis examined the inter-rater reliability and procedural validity of four computerised Bayesian belief networks (BBNs) which were developed to assist with the diagnosis of psychotic disorders. The results of this research indicated that BBNs can significantly improve diagnostic reliability and may represent an important advance over current diagnostic methods. The professional portfolio investigated, through the presentation of case studies and review of literature relevant to each case study, how comorbidity and context of depression may impact on cognitive behavioural therapy treatment.

Healthy or burnout

A model of stress, employee health and intention to quit, was tested among psychiatric nurses. Results indicated that organizational support and employees' sense of control positively mediate the stressor-health relationship at individual and organizational levels, while work-family conflict worsens employee health and increases intention to quit. The professional portfolio explores the association between depression and cognitive functioning, and its impact on the use of cognitive behavioural therapy in the treatment of depression.

The processes through which Affect infuses judgements of subjective well-being

This thesis clarifies the processing routes through which Affect can influence global subjective well-being, and reveals that the strength of these processing routes is moderated by dispositional factors. This has important implications that furthers understanding in the field of subjective well-being. The portfolio focuses on the client characteristics that are indicated to be influential upon the effectiveness, and thus the suitability of cognitive behavioural therapy. Four case studies are presented which illustrate how the suitability of CBT can be influenced by client factors.

Biopsychosocial factors related to Australian and Fijian adolescent body image distortion

The thesis study was a cross-cultural comparison of the biopsychosocial predictors of body image perception and ideals among 294 Australian and 101 Fijian adolescents. The results demonstrated similarities across cultural groups, but parents, peers and the media were stronger influences for Fijians. These findings have implications for body image intervention programs.The portfolio presented a thorough review of the evidence for the cognitive behavioural therapy (CBT) treatment option for adolescents with major depressive disorder (MDD). Four case studies are presented.

Mindfulness in forensic mental health : does it have a role?

Treatment and rehabilitation in forensic settings have been largely based on cognitive behavioural models and therapies. In the past decade, “third wave” approaches have developed in cognitive behavioural therapy, strongly influenced by spiritual and contemplative traditions such as Buddhism. Mindfulness is the most analysed and researched of such approaches. In this paper, we ask whether mindfulness is relevant to therapeutic work with offenders in forensic mental health and criminal justice services. We review the known criminogenic and other needs of offender groups and discuss whether the psychological processes affected by mindfulness are relevant to reducing risk, alleviating distress and facilitating coping. We conclude that they are. Finally, we address some of the problems that may arise in implementing mindfulness interventions in forensic settings.

Perceived control and subjective wellbeing in older adults

Across age, the ability to accept what cannot be changed increases while feelings of control remain stable. The growth of acceptance preserves, rather than compensates for, older adults' sense of being in control. In later life, acceptance and control appear to operate together to maintain wellbeing. The professional portfolio uses four case studies to illustrate how Cognitive Behavioural Therapy (CBT) programs can be reinterpreted through and Acceptance and Committment Therapy (ACT) framework and elements of both employed within a single therapeutic program.

How to integrate the good lives model into treatment programs for sexual offending : an introduction and overview

The good lives model (GLM) represents a new theoretical framework informing sex offender treatment programs; however, substantial variation has been observed in terms of how GLM-related ideas and practices have been applied. Integrated appropriately, the GLM offers potential for improving outcomes of programs following a cognitive-behavioral therapy (CBT) approach and operating according to a narrow operationalization of risk, need, responsivity (RNR) principles. Conversely, misguided or otherwise poor integration could increase the very risk practitioners work to prevent and manage. The purpose of this article is to provide an introduction and overview on how to integrate the GLM into treatment using CBT and RNR. The authors describe clinical implications of the GLM as they relate to program aims and orientation, assessment and intervention planning, content, and delivery

Adaptive autobiographical memory in younger and older adults : the indirect association of integrative and instrumental reminiscence with depressive symptoms

Despite the established effectiveness of reminiscence-based interventions for depression, little research exists into the pathways through which specific reminiscence functions are related to depressive symptoms. Drawing on theory of the mechanisms of change in cognitive-reminiscence therapy, the current study tests the hypothesised indirect associations of adaptive integrative and instrumental reminiscence functions with depressive symptoms and whether these relationships might differ among younger and older adults. Questionnaires were completed by a large community sample of the Australian population. Multiple mediation models were tested in two groups: younger adults (n=730, M age=52.24, SD=9.84) and older adults (n=725, M age= 73.59, SD=6.29). Results were consistent across age groups, indicating that there was direct relationship between these reminiscence functions and depressive symptoms, but that integrative reminiscence is indirectly associated with depressive symptoms through meaning in life, self-esteem, and optimism, and that instrumental reminiscence is indirectly associated with depressive symptoms through primary control and self-efficacy. This study provides support for the relationships between constructs underlying the proposed mechanisms of change in cognitive-reminiscence therapy for the treatment of depression, and suggests these relationships are similar for younger and older adults.

Anxiety online - a virtual clinic : preliminary outcomes following completion of five fully automated treatment programs for anxiety disorders and symptoms

Background : The development of e-mental health interventions to treat or prevent mental illness and to enhance wellbeing has risen rapidly over the past decade. This development assists the public in sidestepping some of the obstacles that are often encountered when trying to access traditional face-to-face mental health care services. Objective : The objective of our study was to investigate the posttreatment effectiveness of five fully automated self-help cognitive behavior e-therapy programs for generalized anxiety disorder (GAD), panic disorder with or without agoraphobia (PD/A), obsessive–compulsive disorder (OCD), posttraumatic stress disorder (PTSD), and social anxiety disorder (SAD) offered to the international public via Anxiety Online, an open-access full-service virtual psychology clinic for anxiety disorders. Methods : We used a naturalistic participant choice, quasi-experimental design to evaluate each of the five Anxiety Online fully automated self-help e-therapy programs. Participants were required to have at least subclinical levels of one of the anxiety disorders to be offered the associated disorder-specific fully automated self-help e-therapy program. These programs are offered free of charge via Anxiety Online. Results : A total of 225 people self-selected one of the five e-therapy programs (GAD, n = 88; SAD, n = 50; PD/A, n = 40; PTSD, n = 30; OCD, n = 17) and completed their 12-week posttreatment assessment. Significant improvements were found on 21/25 measures across the five fully automated self-help programs. At postassessment we observed significant reductions on all five anxiety disorder clinical disorder severity ratings (Cohen d range 0.72–1.22), increased confidence in managing one’s own mental health care (Cohen d range 0.70–1.17), and decreases in the total number of clinical diagnoses (except for the PD/A program, where a positive trend was found) (Cohen d range 0.45–1.08). In addition, we found significant improvements in quality of life for the GAD, OCD, PTSD, and SAD e-therapy programs (Cohen d range 0.11–0.96) and significant reductions relating to general psychological distress levels for the GAD, PD/A, and PTSD e-therapy programs (Cohen d range 0.23–1.16). Overall, treatment satisfaction was good across all five e-therapy programs, and posttreatment assessment completers reported using their e-therapy program an average of 395.60 (SD 272.2) minutes over the 12-week treatment period. Conclusions : Overall, all five fully automated self-help e-therapy programs appear to be delivering promising high-quality outcomes; however, the results require replication.