Abstract
Many community-based surveys have established the high prevalence of mood and anxiety disorders. The 12-month prevalence of anxiety and mood disorders in Australia recently documented in the National Mental Health and Wellbeing Survey is 9.7% and 5.8% respectively.[1] These disorders have been shown to be chronic and disabling.[2], [3], [4] There has been recent interest in the development of the World Health Organization Global Burden of Disease study which reported that the “burden of psychiatric conditions has been heavily underestimated”.[5] In developed nations as reported in 1996, mental disorders contributed 17% of the total burden of disease, with affective disorders accounting for 7.7% and anxiety disorders 2.3% to this figure. The high level of psychiatric comorbidity in patients with mood and anxiety disorders has also been well documented.[4], [6], [7]
The National Mental Health Policy developed in 1992 focussed the delivery of mental health services on a group of patients with “serious mental illness”. In adult psychiatry, this group of patients was most commonly defined as patients with schizophrenia or bipolar affective disorder. The trend towards treating the severely mentally ill addressed the concerns of the government and the community to better manage this very disadvantaged group of patients with mental illness. However, this strategy has been at the expense of providing treatment to other groups of patients with mental illness who have also been shown to be disabled and are now disadvantaged by the current mental health system. For example, in Victoria, this led to a change in public mental health service delivery with patients with anxiety or depressive disorders rarely included in the caseload of a community mental health clinic.
The Depression and Anxiety Research and Treatment (DART) Program, was developed by a group of senior academic clinicians concerned about the lack of treatment available for patients with mood and anxiety disorders. This paper will outline the development of the DART clinical program, which provided assessment and treatment of patients with depression and anxiety.
THE DART PROGRAM
Structure and staffing
In 1996, academic staff from the University of Melbourne Departments of Psychology and Psychiatry joined together to develop a group interested in research in depression and anxiety. This group known as the Depression and Anxiety Research and Treatment (DART) group, subsequently combined with clinicians at the Royal Melbourne Hospital (RMH) to develop a clinical program for the treatment of patients with anxiety and depression. The DART clinical program staff included academic psychiatrists and clinical psychologists, sessional consultant psychiatrists (visiting medical officers), a part-time psychology intern and registrar, clinical psychology students and psychiatry trainees. The group was supported by a full time research assistant.
Aims
The clinical program was developed with the following aims:
to provide clinical services to a range of patients otherwise denied treatment in the public mental health system;
to provide teaching for trainee clinical psychologists, trainee psychiatrists, and medical students;
to develop links with general practitioners, private psychiatrists and clinical psychologists, enabling the development of shared care protocols;
to provide an environment for clinically relevant research.
Intake criteria and referral
Patients were accepted for assessment in the DART program if: living in the catchment area of the four AMHS of the NWHCN; aged between 18 and 65 years; and referred because of an anxiety or mood problem. No patients were excluded from the assessment process and specifically we accepted for assessment patients who were non-English speaking, or who had comorbid problems of substance abuse or personality disorder. All patients were required to have a written referral from either a medical practitioner, Area Mental Health Service, or a clinical psychologist. This was requested to facilitate timely feedback to referral agents regarding assessment outcome and where appropriate to establish shared care arrangements for management.
Assessment procedure
Assessment of patients in the DART program was a three stage process. Patients were initially interviewed by a senior clinician (psychiatrist or clinical psychologist) and assessed by semistructured interview. A Global assessment of Functioning score (GAF)[9] was completed.
The second stage of the assessment used the computerised form of the Composite International Diagnostic Interview (CIDI-Auto) version 2.1; a standardised and highly structured interview which was developed by the World Health Organization,[10] and a variety of self report anxiety and depression rating scales. Most patients completed these without assistance but where appropriate, the CIDI-Auto and rating scales were completed with the research assistant present. Initially several rating scales were used,[11], [12], [13], [14], [15] but after a three month trial these were reduced to two self report measures; the Beck Depression Inventory II[16] and State-Trait Anxiety Inventory[12].
The third stage of the assessment procedure occurred at a weekly assessment meeting where the clinician who completed the interview formally presented the case following which the CIDI results and rating scales were examined. The information presented was discussed by the clinical team, following which the assessing clinician nominated a consensus diagnosis which was then the basis for management decisions.
Management
The clinic established two treatment streams, one for patients presenting for the first time, and one for patients with chronic/recurrent disorders. Three management options were available to the team; treatment in the First Presentation (FP) clinic, or in the Recurrent Mood and Anxiety Disorders (RMA) clinic, or the patient was returned to the referral agency with a detailed assessment and suggestions regarding ongoing management. Individual management plans tailored to the patients needs were developed for all patients.
Criteria for inclusion in the FP Clinic were: a diagnosis of Major Depressive Disorder (MDD), Obsessive Compulsive Disorder (OCD), Panic Disorder ± Agoraphobia (PD, PAG), or Social Phobia (SP); and no previous adequate trial of either psychological or pharmacological treatment. The treatment focus in this clinic was early intervention to reduce symptoms and prevent secondary complications and disability. The FP clinic provided a 12 month treatment program comprising one or more of individual pharmacotherapy, group cognitive behavioural therapy (CBT) and some limited individual cognitive behavioural therapy. Most patients were referred to the group program, but where the clinical needs of the patient were complex or where there was significant comorbidity (especially axis 2 problems), individual CBT was offered.
Criteria for inclusion in the RMA Clinic were: a diagnosis of Major Depressive Disorder (MDD), Bipolar Affective Disorder (BAD), Obsessive Compulsive Disorder (OCD), Panic Disorder ± Agoraphobia (PD, PAG), or Social Phobia (SP); with one or more previous episode. Initially the clinic offered treatment only for MDD, BAD and OCD; patients with PD, PAG, SP were included after 12 months when it became clear that there were few treatment services available for these patients but many were referred to our program. The RMA clinic provided ongoing management in conjunction with the referral source. Treatment of the acute illness episode was followed by systematic review to monitor symptom level, and implement strategies to assist in relapse prevention. The symptom profile, level of disability, and psychosocial problems determined the focus of treatment.
Both FP and RMA clinics utilised a structured group cognitive behavioural program for patients with anxiety disorders. The groups were run jointly by a psychiatrist/trainee psychiatrist and psychologist/ psychology trainee. Trained cognitive–behavioural therapists supervised all therapy. Each of the three group CBT programs utilised standard manualised programs: the OCD group utilised the STOP (Systematic Treatment of Obsessive–compulsive Phenomena) program (M. Kyrios, personal communication), the SP group the Heimberg manual 1991,[17] and the PD group the Barlow manual.[18]
Review and follow up
All patients assessed by the DART program, were reviewed at the clinical meeting three months after initial assessment, and regularly thereafter to ensure they had been engaged in the management strategy planned.
Teaching
The clinic provided clinical experience to: undergraduate medical students who observed clinical assessments and participated in the team meetings; postgraduate clinical psychology students who were therapists in the group CBT program and the most senior of whom participated in assessments, supervision and the team meetings; and psychiatry trainees who were involved in providing individual treatment to patients and were able to participate as co-therapists in the CBT group programs.
Consensus Primary And Comorbid Diagnoses (n = 198)
Two year's clinical experience
The DART program began accepting referrals in February 1997 and assessed 287 patients in its 2 years of operation. Patients were aged 17–71 years with a mean age of 35 years. Twice as many women were referred as men (F 192: M 95). The majority of the patients were single (123), with the rest being married (86), divorced (33), separated (19), de facto relationship (20), widowed (3) and unknown (3).
The referral base for the DART program was primarily general practitioners, many of whom referred several patients (163 of the referrals), followed by private psychiatrists (57) and the Royal Melbourne Hospital (RMH) psychiatry inpatient unit, accident and emergency and consultation liaison services (31). Other referral sources included: the four AMHS of the North Western Healthcare Network (11 patients), community health centres, psychologists, occupational therapists and social workers. A number of self-help groups were aware of the program and encouraged their members to seek appropriate referral from a general practitioner.
Of the 287 patients, 263 completed the three stage assessment process. Of the 24 patients who did not complete the assessment process, twenty-one patients did not attend to complete the CIDI, two patients could not complete the CIDI once started, and one patient did not return to complete a follow up clinical interview.
Multiple diagnoses were commonly made for patients presenting with a mood or anxiety disorder. Consensus primary and comorbid diagnoses made at the assessment meeting are shown in Table 1, for six of the mood and anxiety disorders of interest. Some patients were accorded more than one comorbid diagnosis. Fourteen of the 287 patients referred did not receive a DSM-IV axis 1 or axis 2 diagnoses.
Of the 263 patients who completed the assessment process, 148 were referred to the DART treatment clinics for management, 74 patients were referred to the FP clinic, and 74 patients were referred to the RMA clinic. One hundred and sixteen patients were referred on to another service provider or returned to the referring agent.
Of the 74 patients accepted by the FP clinic for treatment, nine suffered from a primary mood disorder, 32 had panic disorder agoraphobia, 17 had obsessive compulsive disorder, and 16 had social phobia. Table 2 outlines the treatment modalities for each group of disorders.
Of the 74 patients accepted by the RMA clinic, 29 had major depression, two had bipolar disorder, 26 had OCD, 11 had PD or PAG and four had SP. In the first year of the program, the RMA clinic did not accept patients with chronic social phobia or panic disorder. During this time these patients were usually referred to the University-based psychology clinic located at RMH for ongoing management. There was no group program for depression throughout the study period. Table 2 outlines the treatment modalities utilised for each group of disorders.
DISCUSSION
The clinical service described here was established by a group of clinical academics, with the aims and philosophy of the service shaped by their 3 key interests; clinical work, teaching and research. The primary aim of the DART group was to provide a clinical service to those patients currently not often treated in the local public mental health system. In contrast to many “academic” clinical services, we chose to include all patients with anxiety and depressive disorders and did not select only those likely to be suitable for our research activities. This resulted in patients with a variety of comorbid problems being seen, more reflective of what we believe to be a “real world” view of the nature of anxiety and depressive disorders.
The second aim of the Group was educational. This was realised by: clinical placement of trainee clinical psychologists and trainee psychiatrists in the service; provision of a comprehensive report about each patient assessed to their referring clinician outlining in detail the findings of our assessment and management suggestions/plans; and co-management of patients in the RMA clinic with GPs or private psychiatrist/psychologist. The latter was the first step in realising our third aim, the development of formal shared care protocols.
Our fourth aim, to provide an environment for clinically relevant research was frustrated by the closure of the clinical service after 2 years due to lack of funding.
What can be learned from our experience? The need for clinical services for patients with anxiety and depressive disorders is great; in particular GPs enthusiastically referred patients to the Program and were appreciative of both our feedback regarding assessment and management suggestions and the inclusion of their patients in the FP and RMA Clinics. The nature of these problems is such that a variety of treatment approaches are required; comorbidity is common and in those with chronic and/or recurrent disorders disability maybe substantial. A clinical service in which psychologists and psychiatrists work together is well placed to meet this need.
Treatment Modalities Chosen for Patients in the FP Clinic (n = 74) and in the RMA Clinic (n = 74)
Recently, much attention has been focused on depression and its attendant disability. A National Depression Action Plan is being developed. Depression is important, but as seen from our experience it is often intertwined with anxiety. Hopefully the mistakes of definition and focus which excluded patients with anxiety and depression from treatment services for those with “serious mental illness” will not be repeated with the focus on depression rather than depression and anxiety disorders.
Footnotes
Acknowledgements
The development of the clinical service was supported by the Inner West AMHS – The Royal Melbourne Hospital, as was the provision of clinical services over the two year period described here. The authors particularly acknowledge the support of Dr John Fielding, Director of Clinical Services and Ms Jenny Smith, Area Manager.