David Pierce

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 (χ 2 1 = 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.

Australian rural football club leaders as mental health advocates: an investigation of the impact of the Coach the Coach project

BackgroundMental ill health, especially depression, is recognised as an important health concern, potentially with greater impact in rural communities. This paper reports on a project, Coach the Coach, in which Australian rural football clubs were the setting and football coaches the leaders in providing greater mental health awareness and capacity to support early help seeking behaviour among young males experiencing mental health difficulties, especially depression. Coaches and other football club leaders were provided with Mental Health First Aid (MHFA) training.MethodPre-post measures of the ability of those club leaders undertaking mental health training to recognise depression and schizophrenia and of their knowledge of evidence supported treatment options, and confidence in responding to mental health difficulties were obtained using a questionnaire. This was supplemented by focus group interviews. Pre-post questionnaire data from players in participating football clubs was used to investigate attitudes to depression, treatment options and ability to recognise depression from a clinical scenario. Key project stakeholders were also interviewed.ResultsClub leaders (n = 36) who were trained in MHFA and club players (n = 275) who were not trained, participated in this evaluation. More than 50% of club leaders who undertook the training showed increased capacity to recognise mental illness and 66% reported increased confidence to respond to mental health difficulties in others. They reported that this training built upon their existing skills, fulfilled their perceived social responsibilities and empowered them. Indirect benefit to club players from this approach seemed limited as minimal changes in attitudes were reported by players. Key stakeholders regarded the project as valuable.ConclusionsRural football clubs appear to be appropriate social structures to promote rural mental health awareness. Club leaders, including many coaches, benefit from MHFA training, reporting increased skills and confidence. Benefit to club players from this approach was less obvious. However, the generally positive findings of this study suggest further research in this area is desirable.

A brief counselling intervention by health professionals utilising the ‘readiness to change’ concept for women experiencing intimate partner abuse: The weave project

Abstract This paper describes a brief counselling intervention based on the ‘readiness to change’ concept for women experiencing intimate partner violence, and an educational program for training primary care health professionals in the delivery of such an intervention. We present a synthesis of the literature on the Transtheoretical Model of Behaviour and the Psychosocial Readiness to Change Model as applied to intimate partner violence. We describe the intervention used in the weave trial, which draws on the educational and partner violence literature, as well as integrating key theoretical insights from the field of behaviour change. Practical steps for training health professionals are outlined from the authors’ experience and research.

The CORE study protocol: a stepped wedge cluster randomised controlled trial to test a co-design technique to optimise psychosocial recovery outcomes for people affected by mental illness in the community mental health setting

Introduction User engagement in mental health service design is heralded as integral to health systems quality and performance, but does engagement improve health outcomes? This article describes the CORE study protocol, a novel stepped wedge cluster randomised controlled trial (SWCRCT) to improve psychosocial recovery outcomes for people with severe mental illness. Methods An SWCRCT with a nested process evaluation will be conducted over nearly 4 years in Victoria, Australia. 11 teams from four mental health service providers will be randomly allocated to one of three dates 9 months apart to start the intervention. The intervention, a modified version of Mental Health Experience Co-Design (MH ECO), will be delivered to 30 service users, 30 carers and 10 staff in each cluster. Outcome data will be collected at baseline (6 months) and at completion of each intervention wave. The primary outcome is improvement in recovery score using the 24-item Revised Recovery Assessment Scale for service users. Secondary outcomes are improvements to user and carer mental health and well-being using the shortened 8-item version of the WHOQOL Quality of Life scale (EUROHIS), changes to staff attitudes using the 19-item Staff Attitudes to Recovery Scale and recovery orientation of services using the 36-item Recovery Self Assessment Scale (provider version). Intervention and usual care periods will be compared using a linear mixed effects model for continuous outcomes and a generalised linear mixed effects model for binary outcomes. Participants will be analysed in the group that the cluster was assigned to at each time point. Ethics and dissemination The University of Melbourne, Human Research Ethics Committee (1340299.3) and the Federal and State Departments of Health Committees (Project 20/2014) granted ethics approval. Baseline data results will be reported in 2015 and outcomes data in 2017. Trial registration number Australian and New Zealand Clinical Trials Registry ACTRN12614000457640.

Identifying and addressing barriers to the use of enhanced primary care plans for chronic disease in rural practices.

The substantial burden of chronic disease is well established. In Australia, Medicare-funded enhanced primary care (EPC) plans by GPs can be used as a component of chronic disease management. These plans can promote the provision of multidisciplinary care. The potential value of this initiative in supporting team care in a community setting has been recognised as has that barriers might limit its implementation. Use of EPC plans was noted to be consistently below national benchmarks in a medium-size Victorian rural division of general practice. A two-stage response was developed and implemented. Barriers to the use of EPC plans were initially identified. This informed the development of a targeted training intervention to address these barriers.

Factors Promoting Use of Mental Health Services in a Rural Area of Australia

This paper reports research which identified a number of mental health help-seeking responses in a rural region of Australia. It describes the characteristics of services and of individual health professionals, as well as some Australian government initiatives that may promote help seeking behaviours. Focus group and individual interviews were undertaken. Participants included those who had personally experienced mental ill health, family and professional careers of individuals with mental ill health and individuals from rural culturally and linguistically diverse (CALD) communities. The researchers found that while many previously reported factors, such as stigma, limited confidentiality, cost factors, and previous negative experiences with mental health care continue to inhibit help-seeking, a number of responses and initiatives may actively promote help-seeking behaviours. These include: mental health literacy; targeted government schemes; accessible information; continuity of care and affordable services. The paper concludes that promoting these help-seeking enablers may support more desirable outcomes for those experiencing mental-ill healths in rural areas of Australia.

Assumptions associated with mental health literacy training - insights from initiatives in rural Australia

Abstract The impact of depression on the Australian community is well established. A number of approaches have been proposed to address this problem, including targeted programs to promote mental health literacy. This paper explores four assumptions associated with community mental health literacy programs: that individuals would increase their mental health knowledge; increase their confidence to help others experiencing mental ill health; report reduced stigmatising attitudes towards mental illness; and help others experiencing mental ill health. Findings from a rural Victorian community mental health literacy program focused on sports team coaches and other club leaders is reported in the context of these assumptions. Pre–post questionnaire data and focus group data were collected from participants in the mental health literacy program. Participants reported increased knowledge of key mental health conditions, increased confidence to help others experiencing mental ill health and less stigmatizing attitudes toward mental ill health. Limited evidence was noted to support the assumption that, following training, individuals will help others experiencing mental ill health. Difficulties in determining if transfer of benefit to others has occurred following mental health literacy training are discussed, along with a number of mechanisms that, if included in training, may extend the benefit of that mental health literacy training to others.

A systematic review of motivational interviewing in healthcare: the potential of motivational interviewing to address the lifestyle factors relevant to multimorbidity

Internationally, health systems face an increasing demand for services from people living with multimorbidity. Multimorbidity is often associated with high levels of treatment burden. Targeting lifestyle factors that impact across multiple conditions may promote quality of life and better health outcomes for people with multimorbidity. Motivational interviewing (MI) has been studied as one approach to supporting lifestyle behaviour change. A systematic review was conducted to assess the effectiveness of MI in healthcare settings and to consider its relevance for multimorbidity. Twelve meta-analyses pertinent to multimorbidity lifestyle factors were identified. As an intervention, MI has been found to have a small-to-medium statistically significant effect across a wide variety of single diseases and for a range of behavioural outcomes. This review highlights the need for specific research into the application of MI to determine if the benefits of MI seen with single diseases are also present in the context of multimorbidity.

Advancing engagement methods for trials: the CORE study relational model of engagement for a stepped wedge cluster randomised controlled trial of experience-based co-design for people living with severe mental illnesses

BackgroundEngagement is essential in trials research but is rarely embedded across all stages of the research continuum. The development, use, effectiveness and value of engagement in trials research is poorly researched and understood, and models of engagement are rarely informed by theory. This article describes an innovative methodological approach for the development and application of a relational model of engagement in a stepped wedge designed cluster randomised controlled trial (RCT), the CORE study. The purpose of the model is to embed engagement across the continuum of the trial which will test if an experience-based co-design intervention improves psychosocial recovery for people affected by severe mental illness.MethodsThe model was developed in three stages and used a structured iterative approach. A context mapping assessment of trial sites was followed by a literature review on recruitment and retention of hard-to-reach groups in complex interventions and RCTs. Relevant theoretical and philosophical underpinnings were identified by an additional review of literature to inform model development and enactment of engagement activities.ResultsPolicy, organisational and service user data combined with evidence from the literature on barriers to recruitment provided contextual information. Four perspectives support the theoretical framework of the relational model of engagement and this is organised around two facets: the relational and continuous. The relational facet is underpinned by relational ethical theories and participatory action research principles. The continuous facet is supported by systems thinking and translation theories. These combine to enact an ethics of engagement and evoke knowledge mobilisation to reach the higher order goals of the model.ConclusionsEngagement models are invaluable for trials research, but there are opportunities to advance their theoretical development and application, particularly within stepped wedge designed studies where there may be a significant waiting period between enrolment in a study and receipt of an intervention.

Balancing Opposing Forces—A Nested Process Evaluation Study Protocol for a Stepped Wedge Designed Cluster Randomized Controlled Trial of an Experience Based Codesign Intervention The CORE Study

Background: Process evaluations are essential to understand the contextual, relational, and organizational and system factors of complex interventions. The guidance for developing process evaluations for randomized controlled trials (RCTs) has until recently however, been fairly limited. Method/Design: A nested process evaluation (NPE) was designed and embedded across all stages of a stepped wedge cluster RCT called the CORE study. The aim of the CORE study is to test the effectiveness of an experience-based codesign methodology for improving psychosocial recovery outcomes for people living with severe mental illness (service users). Process evaluation data collection combines qualitative and quantitative methods with four aims: (1) to describe organizational characteristics, service models, policy contexts, and government reforms and examine the interaction of these with the intervention; (2) to understand how the codesign intervention works, the cluster variability in implementation, and if the intervention is or is not sustained in different settings; (3) to assist in the interpretation of the primary and secondary outcomes and determine if the causal assumptions underpinning the codesign interventions are accurate; and (4) to determine the impact of a purposefully designed engagement model on the broader study retention and knowledge transfer in the trial. Discussion: Process evaluations require prespecified study protocols but finding a balance between their iterative nature and the structure offered by protocol development is an important step forward. Taking this step will advance the role of qualitative research within trials research and enable more focused data collection to occur at strategic points within studies.