Evidence-Based Reform in Australia

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Overview

The article below details the substantial evidence-base that supports the Better Access program, questioning the decision to cut access for people accessing this program down to just 10 appointments of psychological treatment. Each section provides detailed information linked wherever possible directly to sources where the facts can be directly verified on-line. Summaries of the main points are provided at the end of each section. In short, we contend that the evidence from research shows that 15 to 20 sessions is an appropriate level of psychological treatment to allow people to access when they are experiencing moderate to severe mental health disorders. We directly challenge the view that 10 sessions is enough and question the proposal to redirect funding to programs that have a limited evidence-base and serve far fewer people who need psychological support.

About Evidence-Based Practice

The ‘Better Access’ program is unique amongst mental health initiatives, in that the program is based on well-researched evidence. Decades of painstaking studies have been conducted internationally to identify what types of psychological treatments work best for various mental health conditions across a range of different circumstances. In the evidence-based practice movement there are three critical issues: efficacy, effectiveness, and efficiency. Efficacy research tells us whether a therapeutic technique works. Effectiveness research tells us whether these techniques can be applied in practice with real-world cases. Efficiency research tells us whether these techniques are cost-effective. Put together, the accumulated evidence shows that the Better Access program delivers treatments that work in a cost effective way to real people living in Australian society.

Where To Find The Evidence

Observers would quickly find a considerable amount of research demonstrating that psychotherapy works, especially for the most common conditions, like anxiety, depression, and post-traumatic stress disorder. Large-scale reviews of the evidence date back to the work of Smith and Glass in 1977, but since the 1990s, much more extensive efforts to match specific treatments to disorders, were carried out, beginning with the work of Division 12 of the American Psychological Association. These efforts culminated in the development of a user-friendly web resource for the public to access information about the scientific evidence that underpins psychological treatment, which you can still access here.

In the past two decades, more comprehensive scientific reviews have taken place, looking at recent research that has been conducted across a broad range of treatments for common mental health disorders. Reviews of the evidence in psychological research have been conducted by the Cochrane Collaboration (UK), the National Institute for Health and Clinical Excellence (UK), the National Guideline Clearinghouse (US), the National Registry of Evidence Based Programs and Practices (US), and the US Department of Veteran’s Affairs. Here in Australia, we have also conducted our own rigorous assessment of the evidence, in a review carried out by the Australian Psychological Society (APS) and funded by the Department of Health and Ageing. This review draws together a lot of the evidence from these aforementioned resources, and you can read it right here.

Matching treatments to mental health conditions

In the section below, we go over some of the research that underpins the treatment model used in the Better Access program. For the sake of brevity, this will cover just a few of the common mental health disorders that people experience. Information will be drawn from the resources cited above, looking at the efficacy of psychological treatments, the effectiveness of these techniques, and the efficiency in terms of cost-effectiveness. Given that the current concern with mental health policy in Australia is about the proposal to cap the maximum number of appointments at 10 sessions, information will be provided about the length of treatment that is recommended on the basis of controlled research. When reading the information below, one should also keep in mind that in many cases, people experience co-morbidity of mental health disorders. That is, often people experience difficulties like depression, anxiety or post-traumatic stress disorder in conjunction with one another.

Depression

Last year, the National Institute for Health and Clinical Excellence (NICE) released a 707 page review of the state of research on the treatment and management of depression in adults, also known as the NICE Guidelines for Depression. In total, the NICE Guidelines identify 46 Randomised Controlled Trials (RCTs) supporting cognitive-behavioural therapy (CBT) for depression, with a recommendation for 16 to 20 sessions of therapy for the treatment and relapse prevention of this condition. The NICE review found that many other psychological approaches attain comparable results, particularly IPT and Couples Therapy. These treatments were shown to be cost-effective. None of the recommendations in the NICE Guidelines point to 10 sessions or less. The National Guideline Clearinghouse recommends that those with moderate to severe depression (over 80% of people who receive services in the Better Access program) should have access to 16 to 20 sessions of psychological treatment, based on data from high-quality systematic reviews. A review of treatments for Major Depressive Disorder conducted by the US Department of Veteran’s Affairs in 2009 identified that psychotherapies were applicable for people with mild, moderate and severe symptoms, with CBT, IPT and problem-solving therapies all being appropriate treatment options; and other therapies being appropriate according to the client’s preference. In particular, they recommend continuation of therapy 9 to 12 months after the initial acute symptoms resolve, in order to maintain the gains of treatment and prevent relapse. Similarly, the review conducted by the APS in 2010 shows that there is strong evidence supporting CBT, IPT, and brief dynamic therapy for the treatment of depression. Once again, in the overwhelming majority of cases, 16 to 20 sessions of of individual psychotherapy are recommended for the treatment of depression in adults.

SUMMARY: There is consensus across all of these recent reviews of research about depression that people experiencing depression should be offered at least 16 to 20 sessions of psychological treatment. The Australian federal government decision to offer just 10 sessions falls short of these basic minimal treatment guidelines.

Anxiety

A Cochrane Review was carried out in 2006 which included 22 studies where CBT was applied across a total sample size of 1060 participants with an anxiety disorder. This meta-analysis demonstrated that CBT was highly effective in reducing symptoms of worry and depression associated with Generalised Anxiety Disorder. Earlier this year, NICE released a Guideline for Generalised Anxiety Disorder and Panic Disorder in adults. The guidlines recommend that for those using psychological services, they should be offered at least 12 to 15 sessions as required. The 2010 APS review identifies a strong evidence-base supporting the use of CBT for the treatment of Generalised Anxiety Disorder, Panic, Specific Phobia, Social Anxiety Disorder, and Obsessive Compulsive Disorder. The number of individual psychotherapy sessions across these studies ranged from 10 to 30 appointments. Hence, once again it can be seen that there is considerable evidence for the effectiveness of psychological treatments for anxiety, with recommendations beyond the 10 session mark.

SUMMARY: Although there is more variability in the length of treatment approaches for anxiety, high-quality reviews of the evidence show that psychological interventions for anxiety frequently exceed 10 sessions, with most guidelines recommending between 12 and 30 appointments. The Australian federal government decision to offer just 10 sessions falls short of these basic minimal treatment guidelines.

Post-Traumatic Stress Disorder

A Cochrane Review was conducted in 2007 indicating that Trauma Focused CBT, stress management and EMDR were effective treatments for PTSD. The 2010 US Department of Veteran’s Affairs review of treatments for PTSD contain recommendations both for early intervention (4 to 30 days after exposure to trauma) and the treatment of fully diagnosed PTSD. In the case of early intervention, they recommend 4 to 5 sessions of CBT. In cases where PTSD has developed, the guidelines recommend trauma focused interventions or stress management approaches, with some evidence also in support of other psychotherapy approaches. As pointed out previously, the standard CBT treatment approach ranged between 15 to 20 sessions of therapy. The Australian Guidelines on the Treatment of PTSD developed by the National Health and Medical Research Council in 2007 provide extensive information drawn from several reviews of the research. Following diagnosis, assessment and treatment planning, the guidelines recommend that 8 to 12 sessions of trauma-focused therapy are normally required for the successful treatment of PTSD. In the case of multiple traumatic events, or in instances where there are trauma related bereavements or disabilities, further sessions are indicated. In cases where there are  significant trust issues as a result of a person’s traumatic experiences or difficulties in regulating emotions, the guidelines recommend a more gradual treatment approach. The NHMRC guidelines point out that in many cases 90 minute consultations are needed to carry out therapeutic tasks like imaginal exposure (not presently covered by Medicare). It is worth noting that the guidelines stress the need for realistic and hopeful outcome expectancies.

SUMMARY: Evidence-based treatments for PTSD require at least 8 to 12 sessions of therapy, after the practitioner has assessed, diagnosed and developed a treatment plan for the patient, which can take up to 5 sessions. Reviews for PTSD show that complicating factors associated with the traumatic event itself and difficulties in establishing trust can mean that therapy might take longer than usual. The Australian federal government decision to offer just 10 sessions falls considerably short of these treatment guidelines.

Do Better Access Practitioners Deliver Evidence-Based Treatment?

The decision to cut psychological services down to a maximum of 10 sessions prevents people from accessing a level of treatment that meets scientific standards. These cuts will have the biggest impact on people with moderate to severe mental health disorders and those with low to middle incomes, who are unable to afford psychological services without the support of Medicare.

On the question of whether evidence-based treatment approaches are delivered under the scheme, it is worth pointing out that GPs typically requests a specific treatment approach at the point of referral (such as CBT or IPT). Psychologists are also required to select from evidence-based approaches, both as part of their work in the Medicare system and as a matter of standards within the profession. Continuing professional development within the profession also dictates that practitioners receive ongoing training in evidence-based techniques to use with their clients. Critics of the Better Access program have made unsupported claims to the effect that people who access the program do not receive evidence-based treatment. However, the evidence from consumers in the recent evaluation of the Better Access program confirms that in over 87% of cases clients seeing a psychologist report receiving CBT. Given that there are a variety of other evidence-based approaches available for each condition, and that psychologists are in the best position to tailor their treatment approach to the presenting needs of each individual case, this finding supports the position that mental health practitioners are delivering appropriate services in the Better Access program.

The Better Access program has remarkably strong support by comparison to other programs that are receiving a funding boost in this years federal budget. For example, a portion of the funding that is being withdrawn from the Better Access program is being re-directed into Headspace and EPPIC centres for young people experiencing psychosis.  A recent evaluation report from Headspace states, “there was little tangible evidence of the extent to which services were evidence-based” (p. 125). The evaluation report went on to say “Inclusion of a control group was precluded by the timing, budget and funding requirements for the evaluation, coupled with the introduction of the new model and delayed implementation of the initiative. This limits the validity of the outcomes because it is not possible to determine what would have occurred if young people had not received the headspace intervention” (p. 134). This begs the question of why Commonwealth funds are being diverted away from the Better Access scheme and into initiatives that have far less support across the research. Compounding the problem is that the service cuts bring the maximum length of treatment in the Better Access program below what we know is required for people who access the system.

SUMMARY: There is evidence that over 80% of the people who access the Better Access program have moderate to severe mental health disorders and that over 87% of people who see a psychologist in the program receive evidence-based treatment approaches, such as CBT. Service cuts in the Better Access program will not only bring the length of treatment below the recommended minimum level, but also, the funding that is being withdrawn from the program is being directed into other services that have comparatively less evidence to support them. Funding for new initiatives that currently have limited support in the research should not be drawn from mental health services that have a strong evidence-base

Is 12 Sessions Of Treatment Long Enough?

The original 12 session structure of the Better Access program was primarily built on the largest study of depression in the world, the Treatment of Depression Collaborative Research Program (TDCRP). Unfortunately however, by the time Australia launched the program they did not examine the follow-up data from this trial. One year after treatment had concluded in the TDCRP study, follow up results had found that around 33% of the sample had relapsed. The chief investigators concluded that “The major finding of this study is that 16 weeks of these specific forms of treatment is insufficient for most patients to achieve full recovery and lasting remission” Further to this point, a recent Australian article by Harnett, O’Donovan & Lambert in the July edition of the journal Clinical Psychologist, tracked the progress of 125 clients session-by-session over the course of up to 34 consultations with a psychologist. Using a survival analysis, the researchers found that for 85% of people to show a reliable improvement in their condition they need around 20 consultations with a psychologist. In regards to the Better Access program, where people who meet the criteria for a mental health disorder are initially offered 12 consultations with a psychologist, only a third of people are likely to show a reliable change in their condition at that mark. This is concerning in light of the proposal to cap sessions at 10 appointments.

SUMMARY: What these studies suggest is that closer to 20 sessions are needed to prevent relapse for the most common conditions that are treated in the Better Access program, namely, depression and anxiety. The current maximum length of treatment in the Better Access program, of 18 consultations, is roughly matched to that 20 session standard. If Australia wants to make mental health care a priority, then we need to take heed of the research. Offering just 10 sessions is inadequate and will set many vulnerable and psychologically distressed people up to fail. If anything, the research shows that the Better Access program needs to be expanded instead of restricted.

Conclusions

The Better Access program is unique, in that it allows people to access evidence-based psychological services targeting the broadest range of mental health disorders across the lifespan. Importantly, the structure of the program itself was built to allow people to access a length of psychological treatment that is informed by the highest standards of research, recommended by independent reviewers across the world.  The current system where 12 to 18 sessions are allowable is approximately matched to the minimum standards of care that are recommended for the most common mental health conditions experienced by people living in the general community. Although there is some merit to funding novel treatment approaches for niche areas of special need, it is inappropriate to withdraw funding from the Better Access program and redirect that funding to areas that have far less evidence showing that they are efficacious, effective or efficient models of care. This is particularly problematic when the cuts that are being planned will bring the length of treatment below minimum standards recommended by independent reviewers. We recommend that the Australian federal government leaves the Better Access program intact, and instead, directs a more conservative level of investment towards some of the promising treatment approaches they have identified that target niche areas of the population but have less evidence currently supporting them. In short, the Better Access program should not be traded off against other mental health programs, given the enormous successes of the scheme in helping people across all sectors of the general community access timely psychological treatment when they need it.

What YOU can do about it:

Please support us by signing our petition at Change.org and sharing some of the reasons why you think 10 sessions is not enough. We are calling on all Australians to send an email or write a letter to our politicians, telling them why 10 sessions is not enough. If our policy makers hear us loud and clear in the lead-up to this decision, they will recognise just how important this issue is to Australian society. Even if you haven’t personally struggled with mental health issues, you probably know somebody who does. Please consider just how deeply these issues impact us as a nation, and add your voice to the chorus. Every voice makes a difference!