Caroline Hunt

Why wait? Reasons for delay and prompts to seek help for mental health problems in an Australian clinical sample

Abstract.Background:The initial delay to seek treatment accounts for a significant proportion of the unmet need for treatment of common psychiatric conditions. This study aimed to examine the barriers to initial help-seeking and factors that facilitate help-seeking for anxiety and depression.Methods:Help-seeking history was retrospectively self-reported by 233 patients at a specialist anxiety clinic, all of whom had delayed seeking professional treatment for at least one month. Data gathered included age at onset, age at help-seeking, primary reason for the delay, prompt to seek help and first professional contacted.Results:The most frequently endorsed reasons for the delay related to lack of knowledge about mental illness or available treatment. Increasing illness severity or disability was the primary prompt to seek help for the majority of respondents. Reason for the delay showed some relationship with length of the delay, but prompt to seek help did not. A general medical practitioner (GP) was the first professional contacted in 71% of cases.Conclusions:Lack of public ‘mental health literacy’ contributes to slow problem recognition. Increasing illness severity eventually facilitates problem recognition and prompts help-seeking. Structural barriers to initial help-seeking are relatively unimportant within the Australian health care system. General practitioners play an important role as gate-keepers to appropriate mental health care.

DSM-IV generalized anxiety disorder in the Australian National Survey of Mental Health and Well-Being.

BACKGROUND This paper reports population data on DSM-IV generalized anxiety disorder from the Australian National Survey of Mental Health and Well-Being. METHODS The data were obtained from a nationwide household survey of adults using a stratified multi-stage sampling process. A response rate of 78.1% resulted in 10,641 persons being interviewed. Diagnoses were made using the Composite International Diagnostic Interview. The interview was computerized and conducted by trained lay interviewers. RESULTS Prevalence in the total sample was 2.8% for 1-month GAD and 36% for 12-month GAD. Persons over 55 years of age were less likely to have GAD than those in the younger age groups. Logistic regression analysis also showed that a diagnosis of GAD was significantly associated with being of younger to middle age, being separated divorced or widowed, not having tertiary qualifications or being unemployed. Co-morbidity with another affective, anxiety, substance use or personality disorders was common, affecting 68% of the sample with 1-month DSM-IV GAD. GAD was associated with significant disablement, and 57% of the sample with DSM-IV GAD had consulted a health professional for a mental health problem in the prior 12 months. CONCLUSIONS The survey provides population data on DSM-IV GAD and its correlates. GAD is a common disorder that is accompanied by significant morbidity and high rates of co-morbidity with affective and anxiety disorders, and is associated with marital status, education, employment status, but not sex. Changes to DSM-IV diagnostic criteria did not appear to affect the prevalence rate compared to previous population surveys.

The comorbidity between eating disorders and anxiety disorders: prevalence in an eating disorder sample and anxiety disorder sample.

Objective: To investigate the prevalence of comorbid eating and anxiety disorders in women presenting for inpatient and outpatient treatment of an eating disorder and women presenting for outpatient treatment of an anxiety disorder. Methods: The prevalence of comorbidity was investigated from a sample of 152 women, which included 100 women presenting for treatment of an eating disorder and 52 women presenting for treatment of an anxiety disorder. Results: Of women presenting for treatment of an eating disorder, 65% also met criteria for at least one comorbid anxiety disorder; 69% of these reported the onset of the anxiety disorder to precede the onset of the eating disorder. Of the anxiety disorders diagnosed, social phobia was most frequently diagnosed (42%) followed by post-traumatic stress disorder (26%), generalised anxiety disorder (23%), obsessive–compulsive disorder (5%), panic/agoraphobia (3%) and specific phobia (2%). We also found that 13.5% of women presenting for anxiety treatment also met criteria for a comorbid eating disorder. Furthermore, 71% (n = 5) reported the onset of the anxiety disorder to precede the onset of the eating disorder. Discussion: The results of this study suggest that the prevalence of eating and anxiety disorder comorbidity is high. The present research should improve the clinical understanding of the comorbidity between eating disorders and anxiety disorders. In particular, it is anticipated that this research will have significant aetiological and therapeutic implications especially with regard to improving the clinical effectiveness of psychological treatments for eating disorders and highlighting the importance of screening for eating pathology in the clinical assessment of anxiety disorders.

The effect of compliance-improving interventions on the cognitive-behavioural treatment of pathological gambling.

This exploratory study investigated the effect of interventions designed to improve compliance and reduce dropout rates during the outpatient treatment of pathological gambling at a University-based gambling treatment clinic. Forty subjects (29 males, 11 females, mean age = 37.6) meeting DSM-IV criteria (APA, 1994) for pathological gambling were randomly assigned to either a cognitive-behavioural treatment or a cognitive-behavioural treatment combined with interventions designed to improve treatment compliance. Compliance was indicated by the completion of all treatment sessions. Outcome measures were DSM-IV criteria assessed by structured clinical interview, South Oaks Gambling Screen scores, and percentage of income gambled. Logistic regression analyses identified pretreatment characteristics predicting compliance and outcome. Compliance-improving interventions significantly reduced dropout rates, resulting in superior outcomes at posttreatment compared to the cognitive behavioural treatment alone. At 9-month follow-up, there was no difference in outcome between treatments, although both produced clinically significant change. Comorbid problem drinking, drug use, and problem gambling duration predicted poor compliance. Poor outcome was predicted by comorbid problem drinking. The clinical implications of these results are discussed in light of the exploratory nature of the study and the need for future research to address compliance, outcome, and comorbidity issues.

Development of a measure of the experience of being bullied in youth

The Personal Experiences Checklist (PECK) was developed to provide a multidimensional assessment of a young persons personal experience of being bullied that covered the full range of bullying behaviors, including covert relational forms of bullying and cyber bullying. A sample of 647 school children were used to develop the scale, and a 2nd sample of 218 children completed the PECK and a battery of measures of bullying (including peer nomination), anxiety, depression, and self-esteem, to provide validity evidence. Test-retest reliability was assessed in a further sample of 78 students. Four factors emerged from a principal axis factoring consistent with the domains of relational-verbal bullying, cyber bullying, physical bullying, and bullying based on culture and were confirmed with confirmatory factor analysis. The data also supported a higher order bullying factor with direct effects on these 4 factors. All PECK scales showed good to excellent internal consistency (Cronbachs α range = .78-.91) and adequate test-retest reliability (range r = .61-.86). Most, but not all, expected relations were found with alternative methods of assessing bullying and measures of psychopathology. Taken together, the PECK provides a promising comprehensive and behaviorally focused dimensional measure of bullying.

Culturally attuned Internet treatment for depression amongst Chinese Australians: a randomised controlled trial.

INTRODUCTION Although depression can be treated effectively with Cognitive Behaviour Therapy (CBT), only a small percentage of Chinese Australians access evidence-based treatment due to practical and cultural barriers. The present study examined the efficacy and acceptability of an Internet delivered CBT (iCBT) program to treat Chinese Australians with depression. METHODS The Chinese depression iCBT program (the Brighten Your Mood Program) is a culturally adapted version of the clinically efficacious Sadness iCBT Program. Fifty-five Chinese Australians with depression were randomly allocated to either an immediate treatment group or to a waitlist control group. Treatment consisted of an 8 week program with 6 CBT online educational lessons, homework assignments, additional resources presented in Chinese and English, and weekly telephone support with Mandarin/Cantonese-speaking support personnel. An intention-to-treat model was used for data analyses. RESULTS Seventeen of twenty-five (68%) treatment group participants completed all lessons within the timeframe. Compared to controls, treatment group participants reported significantly reduced symptoms of depression on the Chinese versions of the Beck Depression Inventory (CBDI) and Patient Health Questionnaire-9 item (CB-PHQ-9). The within- and between-group effect sizes (Cohens d) were 1.41 and 0.93 on the CBDI, and 0.90 and 0.50 on the CB-PHQ-9, respectively. Participants rated the procedure as acceptable, and gains were sustained at three-month follow-up. LIMITATIONS The study included several subclinical participants and some measures that have not been previously validated with Chinese Australians. CONCLUSIONS Results provide preliminary support for the efficacy and acceptability of an iCBT program at reducing symptoms of depression in Chinese Australians.

Attentional bias towards threatening stimuli in children with anxiety: A meta-analysis.

Although it is well known that anxious adults show selective attention to threatening stimuli, research investigating attentional bias in children with anxiety has produced mixed results. The purpose of this paper is to provide a comprehensive analysis of studies investigating attentional bias in children with anxiety. Using a systematic search for articles which included both children with anxiety and reported data suitable for a meta-analysis, 38 articles were identified involving 4221 subjects (anxiety n=2222). We used a random effects meta-analysis with standardized mean difference as our primary outcome to estimate between- and within-group effects of attentional bias towards threat-related information in children with anxiety. Overall, children with anxiety showed a significantly greater bias to threat-related stimuli, compared to controls (d=0.21). Children with anxiety also showed a significant bias to threat-related stimuli, over neutral stimuli (d=0.54), which was greater than the bias shown by control children (d=0.15). Specific variables in attentional bias were also explored, with varying results. The review concluded that anxious children do show a similar bias towards threatening stimuli as has been documented in adults, albeit to a lesser degree and this bias is moderated by age, such that the difference between anxious and control children increases with age. Given the small number of studies in some areas, future research is needed to understand the precise conditions under which anxious children exhibit selective attentional biases to threat-related stimuli.

Drop-out rate as a performance indicator in psychotherapy

Many large studies of psychotherapy show that the median patient drops out by the 5th session and most before the 10th session. Data from an effective behavior therapy clinic for the anxiety disorders showed that only 17% of patients failed to complete a median of 60 h of therapy. Patient characteristics were not associated with attrition. We examined 5 meta‐analytic treatment reviews and found the median drop‐out rate was 8% after 20 h of therapy. We suggest that low attrition is associated with effective, standardized treatment and as such, drop‐out rate may be a proxy variable that can indicate effective service delivery.

Evaluation of an Intervention Program for Anxious Adolescent Boys Who Are Bullied at School

PURPOSE This study tested the efficacy of an intervention for anxious adolescent boys experiencing bullying at school. The cognitive-behavioral intervention focused on targeting individual factors that appear to increase an adolescents vulnerability to bullying experiences such as anxiety, low self-esteem, and use of maladaptive coping strategies. METHODS Adolescent boys reporting anxiety symptoms and the recent experience of being bullied at school (grades 7-10) were randomly assigned by group to intervention (n = 22) or wait-list (n = 24) conditions. Depressive and anxiety symptoms and bullying experiences were measured before and after the intervention, and at a 3-month follow-up for the intervention condition. RESULTS The intervention was effective in significantly reducing adolescents bullying experiences as well as their anxiety, depression, and the degree of distress associated with being bullied. Intervention gains were maintained at the 3-month follow-up. The intervention was not effective in enhancing adolescents self-esteem or changing aggressive or avoidant responses to bullying situations. CONCLUSIONS This study provides preliminary support for the value of individually focused interventions for boys in the effort to reduce the incidence of bullying within schools.

Long-term outcome of panic disorder and social phobia.

The question is addressed as to whether cognitive-behavior treatment delivered as a routine service in a specialist clinic is effective in the long term. Of 124 consecutive patients completing treatment for panic disorder or social phobia, 93 were assessed an average of 2 years following treatment. The treatment produced significant improvement in measures of symptoms, avoidance, and disablement during treatment and further significant improvement during the follow-up. A quarter of participants no longer met diagnostic criteria, had not sought further treatment, and their anxiety had not troubled them since treatment. These findings, although not showing the large treatment effects reported from controlled outcome research, support the effectiveness of cognitive-behavioral interventions in routine care.