Pretreatment attrition and dropout in an outpatient clinic for anxiety disorders.

OBJECTIVE: Treatment attrition represents a considerable problem for efficient delivery of care for mental disorders. The present study examined rates and predictors of pretreatment attrition and dropout from outpatient treatment for anxiety disorders. METHOD: The influence of clinical, demographic, clinician and system variables on pretreatment attrition (treatment refusal or non-attendance) and dropout were analysed in a consecutive sample of 731 clients treated at an anxiety disorders clinic in Sydney. RESULTS: Pretreatment attrition was common (30.4%) but dropout once clients had commenced treatment was rare (10.3%). Milder pretreatment symptoms were associated with treatment dropout and comorbid depression or depressive symptoms were associated with higher probability of both pretreatment attrition and dropout. Demographic, clinician and system influences were present but less important. CONCLUSION: Targeting of individuals with comorbid anxiety and depression may reduce treatment attrition rates among individuals with anxiety disorders presenting for treatment.

Modelling the population cost-effectiveness of current and evidence-based optimal treatment for anxiety disorders.

BACKGROUND: The present paper describes a component of a large population cost-effectiveness study that aimed to identify the averted burden and economic efficiency of current and optimal treatment for the major mental disorders. This paper reports on the findings for the anxiety disorders (panic disorder/agoraphobia, social phobia, generalized anxiety disorder, post-traumatic stress disorder and obsessive compulsive disorder). METHOD: Outcome was calculated as averted 'years lived with disability' (YLD), a population summary measure of disability burden. Costs were the direct health care costs in 1997-8 Australian dollars. The cost per YLD averted (efficiency) was calculated for those already in contact with the health system for a mental health problem (current care) and for a hypothetical optimal care package of evidence-based treatment for this same group. Data sources included the Australian National Survey of Mental Health and Well-being and published treatment effects and unit costs. RESULTS: Current coverage was around 40% for most disorders with the exception of social phobia at 21%. Receipt of interventions consistent with evidence-based care ranged from 32% of those in contact with services for social phobia to 64% for post-traumatic stress disorder. The cost of this care was estimated at dollar 400 million, resulting in a cost per YLD averted ranging from dollar 7761 for generalized anxiety disorder to dollar 34 389 for panic/agoraphobia. Under optimal care, costs remained similar but health gains were increased substantially, reducing the cost per YLD to < dollar 20 000 for all disorders. CONCLUSIONS: Evidence-based care for anxiety disorders would produce greater population health gain at a similar cost to that of current care, resulting in a substantial increase in the cost-effectiveness of treatment.

Social phobia in the Australian National Survey of Mental Health and Well-Being (NSMHWB).

BACKGROUND: This article reports data on social phobia from the first large scale Australian epidemiological study. Prevalence rates, demographic correlates and co-morbidity in the sample that met criteria for social phobia are reported and gender differences examined. METHOD: Data were obtained from a stratified sample of 10641 participants as part of the Australian National Survey of Mental Health and Well-Being (NSMHWB). A modified version of the Composite International Diagnostic Interview (CIDI) was used to determine the presence of social phobia, as well as other DSM-IV anxiety, affective and substance use disorders. The interview also screened for the presence of nine ICD-10 personality disorders, including anxious personality disorder, the equivalent of DSM-IV avoidant personality disorder (APD). RESULTS: The estimated 12 month prevalence of social phobia was 2.3%, lower than rates reported in several recent nationally representative epidemiological surveys and closer to those reported in the Epidemiological Catchment Area study (ECA) and other DSM-III studies. Considerable co-morbidity was identified. Data indicated that the co-morbidity with depression and alcohol abuse and dependence were generally subsequent to onset of social phobia and that the additional diagnosis of APD was associated with a greater burden of affective disorder. Social phobia most often preceded major depression, alcohol abuse and generalized anxiety disorder. CONCLUSIONS: Social phobia is a highly prevalent, highly co-morbid disorder in the Australian community. Individuals with social phobia who also screen positively for APD appear to be at greater risk of co-morbidity with all surveyed disorders except alcohol abuse or dependence.

Rationing of health care: clinical decision making in an outpatient clinic for anxiety disorders.

Anxiety disorders are prevalent and disabling and despite the fact that effective interventions are available, many people do not access effective treatment. Clinician decisions are fundamental determinants of access to this treatment. Despite this, treatment decisions have never been examined specifically in this group and are rarely examined in outpatient settings. The present study assessed 550 consecutive referrals to an anxiety disorders clinic in Sydney, Australia. Logistic regression was used to examine the predictors of decisions about treatment. Clinical patient variables (diagnosis and disability) were the strongest predictors of an offer of treatment but demographics and resource availability were also significant. Some of the same factors have been shown to influence the decision to seek treatment for anxiety. Both help-seeking behavior and treatment decision making are important determinants of access to care and both should be examined in future studies.

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.

Shortfall in mental health service utilisation.

BACKGROUND: Treatment coverage for mental disorders is poor in most developed countries. AIMS: To explore some reasons for the poor treatment coverage for mental disorders in developed countries. METHOD: Data were taken from Australian national surveys and from the World Health Report. RESULTS: Only one-third of people with a mental disorder consulted. Probability of consulting varied by diagnosis: 90% for schizophrenia, which is accounted for by external factors; 60% for depression; and 15% for substance use and personality disorders. The probability of consulting varied by gender, age, marital status and disability, from 73% among women aged 25-54 years, disabled and once married to 9% among males without these risk factors. Those who did not consult but were disabled or comorbid said that they "preferred to manage themselves". Data from five countries showed no evidence that overall health expenditure, out-of-pocket cost or responsiveness of the health system affected the overall consulting rates. CONCLUSIONS: Societal, attitudinal and diagnostic variables account for the variation. Funding does not. Public education about the recognition and treatment of mental disorders and the provision of effective treatment by providers might remedy the shortfall.

Why does the burden of disease persist? Relating the burden of anxiety and depression to effectiveness of treatment.

Why does the burden of mental disorders persist in established market economies? There are four possibilities: the burden estimates are wrong; there are no effective treatments; people do not receive treatment; or people do not receive effective treatments. Data from the Australian National Survey of Mental Health and Wellbeing about the two commonest mental disorders, generalized anxiety disorder and depression, have been used in examining these issues. The burden of mental disorders in Australia is third in importance after heart disease and cancer, and anxiety and depressive disorders account for more than half of that burden. The efficacy of treatments for both disorders has been established. However, of those surveyed, 40% with current disorders did not seek treatment in the previous year and only 45% were offered a treatment that could have been beneficial. Treatment was not predictive of disorders that remitted during the year. The burden therefore persists for two reasons: too many people do not seek treatment and, when they do, efficacious treatments are not always used effectively.

Measurement of need for care: a trial of the Camberwell Assessment of Need and the Health of the Nation Outcome Scales.

OBJECTIVE: The accurate assessment of the individual needs of clients has been the focus of increasing discussion in mental health service delivery and evaluation. There is evidence to suggest that clinicians and clients differ in their perceptions of need and that staff assessments alone may not be sufficient for determining need for care. This study addresses these discrepancies in an Australian setting. METHOD: The Camberwell Assessment of Need (short version) and the Health of the Nation Outcome Scales (HoNOS) were completed on a sample of 78 clients of a mental health service in inner Sydney. RESULTS: Clinicians identified a mean number of 7.3 needs per client (SD = 5.0) compared with 6.0 (SD = 2.4) identified by clients. The mean kappa coefficient for agreement between clinicians and clients in identification of the 22 need areas was 0.18 (range = 0-0.45), indicating poor to moderate agreement. Similarly, client ratings of need were only moderately correlated with clinician ratings of disability on the HoNOS (Pearson's r = 0.35). Clinician ratings of disability and unmet need were highly correlated (Pearson's r = 0.80), whereas ratings of disability and met need were moderately correlated (Pearson's r = 0.52). CONCLUSIONS: Individual needs assessments using the CAN are applicable in this Australian setting. Staff and clients differ in their assessment of need. It is important to consider both the role of the rater and the context in which they are making the ratings when applying need and disability assessments in clinical practice.

Recall of depressive episode 25 years previously.

BACKGROUND: Lifetime rates of depression reported in epidemiological surveys are generally only twice the 12 month rates. Either people forget the symptoms of depression or many people who have a depressive episode remain depressed for many years. Both may be true. There is a need to examine the long-term clinical validity of interviews that are used to make lifetime diagnoses. METHODS: Forty-five patients who were part of a long-term follow-up study of depression were interviewed 25 years after the index episode. The diagnoses from the original, fully structured interviews were compared with the responses people made for that period when interviewed using the CIDI 25 years later. RESULTS: Twenty-seven patients met CIDI DSM-III-R criteria for depression at index episode. At the 25 year follow-up, 19 of the 27 reported the essential symptoms of 'depression or loss of interest' being present at the index time, and in 14 of the 27 the depressive symptoms recalled met criteria for DSM-III-R major depressive episode at that time. CONCLUSIONS: Seventy per cent of people who were hospitalized for a major depressive episode can recall being depressed but only half can recall sufficient detail to satisfy the diagnostic criteria when interviewed 25 years later. As depressive episodes, especially those severe enough to warrant admission, are recalled better than many other diagnoses, one must be cautious about the lifetime rates for mental disorders reported in retrospective epidemiological surveys.

Intensive case management in Australia: a randomized controlled trial.

This study compared intensive case management (ICM) with standard clinical case management in a well-resourced community mental health service in Australia. A total of 73 severely disabled clients of an existing clinical service were randomly allocated to either ICM (caseload 10 clients per clinician) or standard case management (caseload up to 30 clients per clinician) and followed up for 12 months. A greater proportion of clients receiving ICM showed improved social functioning, these clients had fewer psychiatric hospital admissions involving police, and were more likely to engage and remain in treatment compared to those who received standard case management. Clients receiving ICM did not show a reduction in hospitalization duration or total number of episodes. It is suggested that future studies of ICM should focus on which aspects of treatment produce positive outcomes, how they can be applied to routine clinical settings, and over what period of time outcomes are sustained.

Intensive case management: a cost-effectiveness analysis.

OBJECTIVE: The objective of this study was to compare the outcomes and costs of intensive case management with routine case management for a group of severely disabled patients with a mental illness. METHOD: A cost-effectiveness analysis was conducted alongside a randomised controlled trial. Seventy-three patients, who reside in the eastern suburbs of Sydney, were randomly allocated to either intensive or routine case management. Staff providing intensive case management and substantially lower caseloads than staff providing routine case management. The main health outcome measured was patients' level of functioning as measured by the Life Skills Profile. Costing data were collected from hospital services, mental health services, general health services, community services and informal carers. RESULTS: At 12 months, outcome and costing data were analysed on 58 patients and hospitalisation data were analysed on 68 patients. Significantly more patients in the intensive case management group remained in treatment (chi 2 = 6.00, df = 1, p < 0.01) and showed a clinically significant improvement in functioning from baseline to 12 months (chi 2 = 4.50, df = 1, p < 0.05). The mean cost per patient was $7745 more in the intensive group than in the routine group (t = 1.49, df = 56, p > 0.01) over 12 months. The cost-effectiveness ratio indicated a cost of $27,661 per year for one additional patient in the intensive case management group to make a clinically significant improvement in functioning. CONCLUSION: Intensive case management led to an increased rate of retention in treatment and a clinically significant improvement in functioning. Further comparative cost-effectiveness studies are required to determine whether $27,661 per year for one patient to make a clinically significant improvement in functioning is a cost-effective use of mental health resources.

Aversive effects of the synthetic cannabinoid CP 55,940 in rats.

A series of experiments investigated the behavioral and hedonic effects of the synthetic cannabinoid CP 55,940 in male Wistar rats. CP 55,940 had a biphasic effect on locomotor activity, with a 10 micrograms/kg dose causing locomotor stimulation and a 100 micrograms/kg dose causing profound hypoactivity. CP 55,940 (100 micrograms/kg) also caused a marked hypothermia for at least 3 h following administration, while lower doses (2.5 and 10 micrograms/kg) had no effect. CP 55,940 (100 micrograms/kg) had anorexic and hyperdipsic effects for up to 24 h following administration and caused significant reductions in body weight. CP 55,940 (100 micrograms/kg) also caused significant avoidance to a flavoured fluid (saccharin) with which it was paired. In the conditioned place preference paradigm both the 10 micrograms/kg and 100 micrograms/kg doses of CP 55,940 produced significant place avoidance. It is concluded that CP 55,940 is aversive to rats. The possible mechanisms underlying this aversion are discussed.