An evaluation of the effect of an educational intervention for Australian social workers on competence in delivering brief cognitive behavioural strategies: a randomised controlled trial

Background

Broad community access to high quality evidence-based primary mental health care is an ongoing challenge around the world. In Australia one approach has been to broaden access to care by funding psychologists and other allied health care professionals to deliver brief psychological treatments to general practitioners' patients. To date, there has been a scarcity of studies assessing the efficacy of social worker delivered psychological strategies. This study aims to build the evidence base by evaluating the impact of a brief educational intervention on social workers' competence in delivering cognitive behavioural strategies (strategies derived from cognitive behavioural therapy).

Methods

A randomised controlled trial design was undertaken with baseline and one-week follow-up measurement of both objective and self-perceived competence. Simulated consultations with standardised depressed patients were recorded on videotape and objective competence was assessed by blinded reviewers using the Cognitive Therapy Scale. Questionnaires completed by participants were used to measure self-perceived competence. The training intervention was a 15 hour face-to-face course involving presentations, video example consultations, written materials and rehearsal of skills in pairs.

Results

40 Melbourne-based (Australia) social workers enrolled and were randomised and 9 of these withdrew from the study before the pre training simulated consultation. 30 of the remaining 31 social workers (97%) completed all phases of the intervention and evaluation protocol (16 from intervention and 14 from control group). The intervention group showed significantly greater improvements than the control group in objective competence (mean improvement of 14.2 (7.38-21.02) on the 66 point Cognitive Therapy Scale) and in subjective confidence (mean improvement of 1.28 (0.84-1.72) on a 5 point Likert scale). On average, the intervention group improved from below to above the base competency threshold on the Cognitive Therapy Scale whilst the control group remained below.

Conclusions

Social workers can attain significant improvements in competency in delivering cognitive behavioural strategies from undertaking brief face to face training. This is relevant in the context of health reforms that involve social worker delivery of evidence based psychological care. Further research is required to assess how these improvements in competence translate into performance in practice and clinical outcomes for patients.

Establishing the Victorian Primary Care Practice Based Research Network

BACKGROUND

Practice based research networks comprise research academics and primary care practitioners who have the mutual goal of supporting the development and implementation of research that is necessary to build the evidence base that informs both primary healthcare practitioners and policy makers. This article describes the establishment of the Victorian Primary Care Practice Based Research Network (VicReN), which was established in 2007 and has grown to over 100 members.

METHOD

The aim of this article is to discuss the key factors in the development of the organisational structure of VicReN, and to describe the outcome measures used to evaluate the network.

RESULTS

VicReN has a diverse primary care membership. Members' different research needs have been addressed through numerous capacity building activities. The absence of core funding beyond the development phase has led to an innovative funding model.

DISCUSSION

This article outlines a viable and sustainable background practice based research network model in the Australian environment that may assist other academic departments of general practice and rural health interested in establishing a practice based research network.

The association between intimate partner violence, alcohol and depression in family practice

Background

Depressive symptoms, intimate partner violence and hazardous drinking are common among patients attending general practice. Despite the high prevalence of these three problems; the relationship between them remains relatively unexplored.

Methods

This paper explores the association between depressive symptoms, ever being afraid of a partner and hazardous drinking using cross-sectional screening data from 7667 randomly selected patients from a large primary care cohort study of 30 metropolitan and rural general practices in Victoria, Australia. The screening postal survey included the Center for Epidemiological Studies Depression Scale, the Fast Alcohol Screening Test and a screening question from the Composite Abuse Scale on ever being afraid of any intimate partner.

Results

23.9% met criteria for depressive symptoms. A higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0) and a lower proportion of females (12%) than males (25%) were hazardous drinkers (OR 0.4; 95%CI 0.4 to 0.5); and a higher proportion of females than males (20.8% vs. 7.6%) reported ever being afraid of a partner during their lifetime (OR 3.2, 95%CI 2.5 to 4.0). Men and women who had ever been afraid of a partner or who were hazardous drinkers had on average higher depressive symptom scores than those who had never been afraid or who were not hazardous drinkers. There was a stronger association between depressive symptoms and ever been afraid of a partner compared to hazardous drinking for both males (ever afraid of partner; Diff 6.87; 95% CI 5.42, 8.33; p < 0.001 vs. hazardous drinking in last year; Diff 1.07, 95% CI 0.21, 1.94; p = 0.015) and females (ever afraid of partner; Diff 5.26; 95% CI 4.55, 5.97; p < 0.001 vs. hazardous drinking in last year; Diff 2.23, 95% CI 1.35, 3.11; p < 0.001), even after adjusting for age group, income, employment status, marital status, living alone and education level.

Conclusions

Strategies to assist primary care doctors to recognise and manage intimate partner violence and hazardous drinking in patients with depression may lead to better outcomes from management of depression in primary care.

Diverse voices, simple desires: a conceptual design for primary care to respond to depression and related disorders

BACKGROUND

The World Health Organization and the World Organization of Family Doctors have called for 'doable' and 'limited' tasks to integrate mental health into primary care. Little information is provided about tasks GPs can undertake outside of guidelines that suggest to prescribe medication and refer to specialists.

OBJECTIVES

The reorder study aimed to gather diverse patient and community perspectives to inform the development of an effective system of depression care.

METHOD

Five hundred and seventy-six patients completed computer-assisted telephone interviews. Two hundred and seventy-six community stakeholders completed a modified two round Delphi. Responses were analysed to identify tasks and these were synthesised into a conceptual design.

RESULTS

Fifteen core tasks were identified, 5 were agreed upon and a further 10 identified by each group but not agreed upon. Listen, understand and empathize, provide thorough and competent diagnosis and management, follow-up and monitor patients, be accessible and do not rush appointments and provide holistic approach and tailor care to individual needs were agreed on. Other tasks included: develop plans with patients, assess for severity and suicide risk, account for social factors, be well trained in depression care and offer a range of treatment options, appropriate and timely referral, support and reassurance, educate patients about depression, prescribe appropriately and manage medication and be positive and encouraging.

CONCLUSIONS

The tasks form the basis of a conceptual design for developing a primary care response to depression. They fit within three domains of care: the relational, competency and systems domains. This illustrates tasks for GPs beyond prescription and referral.

Validation of PHQ-2 and PHQ-9 to screen for major depression in the primary care population

PURPOSE

Although screening for unipolar depression is controversial, it is potentially an efficient way to find undetected cases and improve diagnostic acumen. Using a reference standard, we aimed to validate the 2- and 9-question Patient Health Questionnaires (PHQ-2 and PHQ-9) in primary care settings. The PHQ-2 comprises the first 2 questions of the PHQ-9.

METHODS

Consecutive adult patients attending Auckland family practices completed the PHQ-9, after which they completed the Composite International Diagnostic Interview (CIDI) depression reference standard. Sensitivities and specificities for PHQ-2 and PHQ-9 were analyzed.

RESULTS

There were 2,642 patients who completed both the PHQ-9 and the CIDI. Sensitivity and specificity of the PHQ-2 for diagnosing major depression were 86% and 78%, respectively, with a score of 2 or higher and 61% and 92% with a score 3 or higher; for the PHQ-9, they were 74% and 91%, respectively, with a score of 10 or higher. For the PHQ-2 a score of 2 or higher detected more cases of depression than a score of 3 or higher. For the PHQ-9 a score of 10 or higher detected more cases of major depression than the PHQ determination of major depression originally described by Spitzer et al in 1999.

CONCLUSIONS

We report the largest validation study of the PHQ-2 and PHQ-9, compared with a reference standard interview, undertaken in an exclusively primary care population. The PHQ-2 score or 2 or higher had good sensitivity but poor specificity in detecting major depression. Using a PHQ-2 threshold score of 2 or higher rather than 3 or higher resulted in more depressed patients being correctly identified. A PHQ-9 score of 10 or higher appears to detect more depressed patients than the originally described PHQ-9 scoring for major depression.

Managing depression among ethnic communities: a qualitative study

PURPOSE

Clinical care for depression in primary care negotiates a path between contrasting views of depression as a universal natural phenomenon and as a socially constructed category. This study explores the complexities of this work through a study of how family physicians experience working with different ethnic minority communities in recognizing, understanding, and caring for patients with depression.

METHODS

We undertook an analysis of in-depth interviews with 8 family physicians who had extensive experience in depression care in 3 refugee patient groups in metropolitan Victoria and Tasmania, Australia.

RESULTS

Although different cultural beliefs about depression were acknowledged, the physicians saw these beliefs as deeply rooted in the recent historical and social context of patients from these communities. Traumatic refugee experiences, dislocation, and isolation affected the whole of communities, as well as individuals. Physicians nevertheless often offered medication simply because of the impossibility of addressing structural issues. Interpreters were critical to the work of depression care, but their involvement highlighted that much of this clinical work lies beyond words.

CONCLUSIONS

The family physicians perceived working across cultural differences, working with biomedical and social models of depression, and working at both community and individual levels, not as a barrier to providing high-quality depression care, but rather as a central element of that care. Negotiating the phenomenon rather than diagnosing depression may be an important way that family physicians continue to work with multiple, contested views of emotional distress. Future observational research could more clearly characterize and measure the process of negotiation and explore its effect on outcomes.

Negotiations of distress between East Timorese and Vietnamese refugees and their family doctors in Melbourne

Recent critiques of depression have contested its coherence as a concept and highlighted its performance in medicalising distress. Studies of depression in a cross-cultural context have focused on language and belief systems as technical barriers to practice that need to be overcome in enacting depression work. This paper seeks to locate culture within the broader socio-structural context of depression care in general practice. The paper draws on interviews with five general practitioners (GPs), and 24 patients from Vietnamese and East Timorese backgrounds who predominantly have left their home as refugees. Each had been diagnosed with depression or prescribed antidepressants. These patients gave accounts of distress deeply embedded within, and inseparable from, lives fraught with frightening pre-migration experiences, traumatic escape and profound dislocation and alienation in their new 'home'. Fragmented lives were contrasted with the nourishing social fabric of homes left behind. GP participants were involved in a process of engaging with a profoundly communal and structural account of emotional distress while defending and drawing on an individualised notion of depression in performing their work and accounting for the pain presented to them.

Cherenkov-type diamond detectors for measurements of fast electrons in the TORE-SUPRA tokamak

The paper presents a schematic design and tests of a system applicable for measurements of fast electron pulses emitted from high-temperature plasma generated inside magnetic confinement fusion machines, and particularly in the TORE-SUPRA facility. The diagnostic system based on the registration of the Cherenkov radiation induced by fast electrons within selected solid radiators is considered, and electron low-energy thresholds for different radiators are given. There are some estimates of high thermal loads, which might be deposited by intense electron beams upon parts of the diagnostic equipment within the TORE-SUPRA device. There are some proposed measures to overcome this difficulty by the selection of appropriate absorption filters and Cherenkov radiators, and particularly by the application of a fast-moving reciprocating probe. The paper describes the measuring system, its tests, as well as some results of the preliminary measurements of fast electrons within TORE-SUPRA facility.

Outcomes and costs of primary care surveillance and intervention for overweight or obese children: the LEAP 2 randomised controlled trial

OBJECTIVE

To determine whether ascertainment of childhood obesity by surveillance followed by structured secondary prevention in primary care improved outcomes in overweight or mildly obese children.

DESIGN

Randomised controlled trial nested within a baseline cross sectional survey of body mass index (BMI). Randomisation and outcomes measurement, but not participants, were blinded to group assignment.

SETTING

45 family practices (66 general practitioners) in Melbourne, Australia.

PARTICIPANTS

3958 children visiting their general practitioner in May 2005-July 2006 were surveyed for BMI. Of these, 258 children aged 5 years 0 months up to their 10th birthday who were overweight or obese by International Obesity Taskforce criteria were randomised to intervention (n=139) or control (n=119) groups. Children who were very obese (UK BMI z score >or=3.0) were excluded.

INTERVENTION

Four standard consultations over 12 weeks targeting change in nutrition, physical activity, and sedentary behaviour, supported by purpose designed family materials. Main outcomes measures Primary measure was BMI at 6 and 12 months after randomisation. Secondary measures were mean activity count/min by 7-day accelerometry, nutrition score from 4-day abbreviated food frequency diary, and child health related quality of life. Differences were adjusted for socioeconomic status, age, sex, and baseline BMI.

RESULTS

Of 781 eligible children, 258 (33%) entered the trial; attrition was 3.1% at 6 months and 6.2% at 12 months. Adjusted mean differences (intervention - control) at 6 and 12 months were, for BMI, -0.12 (95% CI -0.40 to 0.15, P=0.4) and -0.11 (-0.45 to 0.22, P=0.5); for physical activity in counts/min, 24 (-4 to 52, P=0.09) and 11 (-26 to 49, P=0.6); and, for nutrition score, 0.2 (-0.03 to 0.4, P=0.1) and 0.1 (-0.1 to 0.4, P=0.2). There was no evidence of harm to the child. Costs to the healthcare system were significantly higher in the intervention arm.

CONCLUSIONS

Primary care screening followed by brief counselling did not improve BMI, physical activity, or nutrition in overweight or mildly obese 5-10 year olds, and it would be very costly if universally implemented. These findings are at odds with national policies in countries including the US, UK, and Australia.

TRIAL REGISTRATION

ISRCTN 52511065 (www.isrctn.org).

Managing depression in a changing primary mental healthcare system: comparison of two snapshots of Australian GPs' treatment and referral patterns

Background Significant government spending has resulted in substantial changes to the Australian primary mental healthcare system. Initially producing the Better Outcomes in Mental Health Care (BOiMHC) initiative, this has been replaced by the Better Access to Mental Health Care programme, which allows all general practitioners (GPs) to refer patients for allied psychological health care under Medicare. Aim To examine changes in patient management and referral for care following the BOiMHC initiative.Method Comparison of results of a 2006 postal survey of Australian GPs examining self-reported management of patients with depression with a similar survey conducted in 2001-2002, prior to the BOiMHC initiative.Results One hundred and thirty-three (33%) GPs responded. The main self-reported strategies for managing patients with depression were similar to the previous study: supportive counselling and medication. No significant difference was found in rates of self-reported formal training in psychological treatments. Significantly higher rates of referral for psychological treatments were reported in 2006 than in 2002. Small trends towards higher reported referral for and reported use of psychological treatments by GPs registered for the BOiMHC initiative were noted when compared with those who were not registered.Conclusion While GPs' main reported strategies for managing patients with depression were unchanged, reported referral for psychological therapies was significantly higher in 2006, possibly reflecting the impact of changes to the primary mental healthcare system. Ongoing rigorous evaluation of further changes to the primary mental healthcare system are needed to determine whether they deliver effective, evidence-based care, and thus to inform future programmes.

Bone attachment to glass-fibre-reinforced composite implant with porous surface

A method has recently been developed for producing fibre-reinforced composites (FRC) with porous surfaces, intended for use as load-bearing orthopaedic implants. This study focuses on evaluation of the bone-bonding behaviour of FRC implants. Three types of cylindrical implants, i.e. FRC implants with a porous surface, solid polymethyl methacrylate (PMMA) implants and titanium (Ti) implants, were inserted in a transverse direction into the intercondular trabeculous bone area of distal femurs and proximal tibias of New Zealand White rabbits. Animals were sacrificed at 3, 6 and 12 weeks post operation, and push-out tests (n=5-6 per implant type per time point) were then carried out. At 12 weeks the shear force at the porous FRC-bone interface was significantly higher (283.3+/-55.3N) than the shear force at interfaces of solid PMMA/bone (14.4+/-11.0 N; p<0.001) and Ti/bone (130.6+/-22.2N; p=0.001). Histological observation revealed new bone growth into the porous surface structure of FRC implants. Solid PMMA and Ti implants were encapsulated mostly with fibrous connective tissue. Finite element analysis (FEA) revealed that porous FRC implants had mechanical properties which could be tailored to smooth the shear stress distribution at the bone-implant interface and reduce the stress-shielding effect.

Development of a theory of implementation and integration: Normalization Process Theory

BACKGROUND

Theories are important tools in the social and natural sciences. The methods by which they are derived are rarely described and discussed. Normalization Process Theory explains how new technologies, ways of acting, and ways of working become routinely embedded in everyday practice, and has applications in the study of implementation processes. This paper describes the process by which it was built.

METHODS

Between 1998 and 2008, we developed a theory. We derived a set of empirical generalizations from analysis of data collected in qualitative studies of healthcare work and organization. We developed an applied theoretical model through analysis of empirical generalizations. Finally, we built a formal theory through a process of extension and implication analysis of the applied theoretical model.

RESULTS

Each phase of theory development showed that the constructs of the theory did not conflict with each other, had explanatory power, and possessed sufficient robustness for formal testing. As the theory developed, its scope expanded from a set of observed regularities in data with procedural explanations, to an applied theoretical model, to a formal middle-range theory.

CONCLUSION

Normalization Process Theory has been developed through procedures that were properly sceptical and critical, and which were opened to review at each stage of development. The theory has been shown to merit formal testing.

A qualitative analysis of a focus group discussion on patient decision making in cancer care

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Background: Patient preferences should play an important role when decision making in cancer care. Literature is increasingly demonstrating that surgeons and physicians have divergent preferences for treatment options compared with their patients and with each other. Cancer psychology is an important aspect of cancer care. Qualitative research is a gateway to explore this. We aim to explore opinions and thoughts among surgical colleagues about “patient decision making in cancer care”. Methods: A pilot focus group discussion among members of the academic surgical unit involving 4 consultants, 3 registrars and 3 research fellows. The discussion was audio-taped and transcribed. Qualitative methodology was adopted for analysis. Thematic analysis using framework approach was done thereby identifying Themes & Outcomes. Results: Themes that emerged are Evidence based clinical practice, Knowledge, Decision making, Patient Information, Risk, Communication, Consent, Socioeconomic factors and Patient empowerment, Outcomes derived are to increase the evidence base, Increase the clinician and patient knowledge, provide adequate information, Decisions to be based on patients best interest, Communicate risk in a understandable manner, Take patients views, knowledge and demands into consideration, Conclusions: Patient decision making in cancer care is slowly evolving, where decisions are not only made taking into account patients views, knowledge and demand but are also driven by them in a minority. Time is a factor and in years to come the patients will play an increased role in their treatments taking into account tradeoffs and risks between survival and quality of life.

No significant financial relationships to disclose.

The politics of conducting research on depression in a cross-cultural context

Successful community engagement is often a crucial component of effective qualitative research. In this article we reflect on our experience of engaging with ethnic minority communities in a qualitative study of help seeking for depression. Community engagement emerges as a complex process that provides important insights into the way mental illness is constructed in various cultural contexts and from diverse perspectives. Contested notions of ethnicity, culture, community, and depression were the domains in which personal and public politics were played out. We worked with bilingual research assistants who provided an entrée to the community. Despite this, disparate community subgroups and influential individuals vied for input into and control of the research agenda. We conclude that negotiating the politics of these processes requires great reflexivity and is itself a powerful seam of data, adding richness to findings about the experience of mental distress in a community seeking to locate itself within mainstream society.

How could depression guidelines be made more relevant and applicable to primary care? A quantitative and qualitative review of national guidelines

BACKGROUND

Many guidelines have been developed in the area of depression but there has been no systematic assessment of their relevance to general practice.

AIM

To assess national guidelines on general practice management of depression using two complementary approaches to identify specific ways in which guidance could be made more relevant and applicable to the nature of general practice and the patients who seek help in this context.

DESIGN OF STUDY

Review of national guidelines.

SETTING

Seven English speaking countries: UK, US, Australia, New Zealand, Ireland, Canada, and Singapore.

METHOD

Seven guidelines were independently reviewed quantitatively using the Appraisal of Guidelines for Research and Evaluation (AGREE) scores and qualitatively using thematic coding.

RESULTS

The quantitative assessment highlights that most of the guidelines fail to meet the criteria on rigour of development, applicability, and editorial independence. The qualitative assessment shows that the majority of guidelines do not address associated risk factors sufficiently and the dilemma of diagnostic uncertainty flows over into management recommendations. Management strategies for depression (antidepressants and psychological strategies) are supported by all of the guidelines, with several listing drugs before psychological therapies; there is limited attention paid to the different types of psychological therapies. Moreover, the guidelines in the main fail to acknowledge individual patient circumstances, in particular the influence on response to treatment of social issues such as adverse life events or social support.

CONCLUSION

Assessments of current national guidelines on depression management in general practice suggest significant limitations in their relevance to general practice.

Publish or perish? Evaluation of a writing week

BACKGROUND

To improve research publication output, a general practice department in Australia declared a department wide 'writing week'.

METHOD

Components included: pre-registration, an initial presentation followed by scheduled one-on-one sessions with an external facilitator, a progress 'running sheet', voucher incentives, and a concluding session for shared feedback and 'prize giving'.

RESULTS

Ninety percent (18/90) of potential staff participated, from novice to senior. In the subsequent 3 months eight papers were submitted and a further nine were nearing completion. Expressed benefits were having dedicated and structured time, collegial support and an external facilitator.

DISCUSSION

While effectiveness of writing week could not be precisely measured with respect to publication outputs, researchers, regardless of seniority, benefited from the provision of structural knowledge, quarantined time and/or support to write up research.