Development of the private practice management standards for psychology.

This paper describes the process of developing a set of private practice management standards to support Australian psychologists and promote high quality services to the public. A review of the literature was conducted to identify management standards relevant to psychology, which were further developed in consultation with a panel of experts in psychology or in the development of standards. Forty-three psychologists in independent private practice took part in either a survey (n=22) to provide feedback on the relevance of, and their compliance with, the identified standards, or a 6-month pilot study (n=21) in which a web-based self-assessment instrument evaluating the final set of standards and performance indicators was implemented in their practice to investigate self-reported change in management procedures. The pilot study demonstrated good outcomes for practitioners when evaluation of compliance to the standards was operationalized in a self-assessment format. Study results are based on a small sample size. Nevertheless, relevance and utility of the standards was found providing an initial version of management standards that have relevance to the practice of psychology in Australia, along with a system for evaluating psychological service provision to ensure best practice in service delivery.

The psychosocial profile of adolescent risk of homelessness.

OBJECTIVE: To contrast the psychosocial profile of adolescents with risk factors for homelessness, identified using Chamberlain and MacKenzie's self-report scale, compared to the profiles of homeless adolescents. METHODS: Multinomial logistic regression analyses were conducted contrasting profiles for (a) 137 homeless adolescents, (b) 766 secondary students reporting risk factors for homelessness, and (c) 4,844 students not reporting risks for homelessness. RESULTS: Fourteen percent of a representative population of at-school adolescents, from Victoria, Australia, showed elevated risk of homelessness. These adolescents showed depressive symptoms at least equivalent to homeless adolescents (RR 6.0, 95% CI: 4.9, 7.3, and RR 3.5, 95% CI: 2.1, 5.8, respectively). In multivariate analyses, homeless and at risk adolescents reported equivalent levels of family conflict, early problem behaviour and low opportunities and rewards for family involvement. Compared to adolescents not at risk, at risk adolescents were more likely to be female and to show poorer social skills/assertiveness and depressive symptoms. Compared to at risk adolescents, homeless adolescents showed additional family, school, peer and individual risks, but lower depressive symptomatology. CONCLUSIONS: The findings highlight the potential we have to quickly and simply detect adolescents showing significant risk of homelessness. This sizable minority of adolescents report risks often equivalent to homeless adolescents. It is hoped that stakeholders working with young people will utilise this screening potential to identify and intervene effectively with this significant subpopulation of youth, and their families, while they are still at home and school.

Psychotherapy in Australia: clinical psychology and its approach to depression.

In Australia, clinical psychology training is dominated by cognitive and behavioral treatments (CBTs), although there is exposure to other theoretical orientations. Since 2001, over 20% of general medical practitioners (GPs) have received training in CBT, and psychiatry training increasingly incorporates CBT elements. Psychotherapy by medical practitioners is financially supported by universal health care funding with supplementation by patients and their private health insurance. Federally funded health benefits for up to 12 psychology consultations per year are provided on referral from GPs and psychiatrists, and initial takeup has been very strong. Mrs. A would be a typical patient for such a referral. However, she would not fulfill criteria for priority access from state-funded mental health services. Mrs. A would probably consult a GP and receive antidepressants, although she may also access a range of other community support programs. Access to and acceptance of psychotherapy would be greater in urban areas, and if she were of Anglo-Saxon and non-indigenous origin.

Child and family predictors of therapy outcome for children with behavioral and emotional problems.

This study investigated the characteristics of 106 children primarily referred for externalizing behavior problems and their families, and assessed the prediction of treatment outcome following a standardized short-term, cognitive behavioral group program. Exploring Together comprised a children's group (anger management, problem-solving and social skills training), a parents' group (parenting skills training, dealing with parents' personal, relationship and family-of-origin issues), and a combined children's and parents' group (to target parent-child interactions). The main predictors of reductions in externalizing and internalizing behaviors at home following treatment were children's pre-existing levels of these behavioral and emotional problems (children with higher levels improved most), and positive parent-child interaction. Higher pre-existing levels of behavioral and emotional problems and low levels of attention problems predicted greater improvement in post-treatment school behaviors. Implications of the findings for improving interventions for childhood behavioral and emotional problems are discussed.

Cost-effectiveness of cognitive behavioural therapy and selective serotonin reuptake inhibitors for major depression in children and adolescents.

OBJECTIVE: To assess from a health sector perspective the incremental cost-effectiveness of cognitive behavioural therapy (CBT) and selective serotonin reuptake inhibitors (SSRIs) for the treatment of major depressive disorder (MDD) in children and adolescents, compared to "current practice". METHOD: The health benefit is measured as a reduction in disability-adjusted life years (DALYs), based on effect size calculations from meta-analysis of randomised controlled trials. An assessment on second stage filter criteria ("equity", "strength of evidence", "feasibility" and "acceptability to stakeholders") is also undertaken to incorporate additional factors that impact on resource allocation decisions. Costs and benefits are tracked for the duration of a new episode of MDD arising in eligible children (age 6-17 years) in the Australian population in the year 2000. Simulation-modelling techniques are used to present a 95% uncertainty interval (UI) around the cost-effectiveness ratios. RESULTS: Compared to current practice, CBT by public psychologists is the most cost-effective intervention for MDD in children and adolescents at A$9000 per DALY saved (95% UI A$3900 to A$24 000). SSRIs and CBT by other providers are less cost-effective but likely to be less than A$50 000 per DALY saved (> 80% chance). CBT is more effective than SSRIs in children and adolescents, resulting in a greater total health benefit (DALYs saved) than could be achieved with SSRIs. Issues that require attention for the CBT intervention include equity concerns, ensuring an adequate workforce, funding arrangements and acceptability to various stakeholders. CONCLUSIONS: Cognitive behavioural therapy provided by a public psychologist is the most effective and cost-effective option for the first-line treatment of MDD in children and adolescents. However, this option is not currently accessible by all patients and will require change in policy to allow more widespread uptake. It will also require "start-up" costs and attention to ensuring an adequate workforce.

Outcome evaluation of a statewide child inpatient mental health unit.

OBJECTIVE: To assess the impact of inpatient intervention, provided by a child mental health unit in Victoria, Australia, on a number of key child and family variables. METHOD: Pre-post test design with a four-month follow up was applied to assess changes across time. Twenty-nine parents, 42 teachers, and 37 referrers provided reports on a series of child, parent, and family functioning measures. RESULTS: Significant improvements in child behaviour and functioning, parenting competency and efficacy, parenting practices, and reduced parental depression were observed over time. Changes in family functioning scores were not significant; however, univariate analysis indicated improvements in two individual subscales. CONCLUSIONS: There is a lack of studies of the outcome of inpatient interventions of children in psychiatric settings. However, as shown in the present study, improvements in functioning can be detected and obtained with short-term interventions that focus on both children and families. Methodological shortcomings (i.e. absence of comparison groups) and lack of specificity in intervention variables, however, are difficulties yet to be overcome in evaluation research of inpatient treatment.