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Mood and anxiety disorders rank among the most prevalent mental health disorders in Ontario (1) and North America (2,3). Together these disorders are among the largest contributors to workplace disability, family dysfunction, and individual suffering. For example, depression has been estimated to cause 172 million lost workdays yearly in the US alone (4). According to the 1994 Mental Health Supplement to the Ontario Health Survey (1), 18.6% of the population had a significant psychiatric disorder (excluding schizophrenia and personality disorders). Of these individuals, 82.9% used general medical services but only 20.8% reported seeking mental health help, either from a family physician or a mental health provider (5). More specifically, the 1-year prevalence rate for major depression was 4.1%. Of these individuals, one-half did not seek mental health treatment, 22.2% received some type of counselling intervention without any medication, 18.0% received antidepressants, and 8.7% received anxiolytics without antidepressants (6). These figures highlight 2 major observations: psychiatric disorders and depression often remain untreated, though the same individuals use general medical services for other health problems. From a health systems perspective, effective management of chronic illnesses like depression should rely heavily on the primary care sector (7), and the Ontario data suggest that patients with depression are indeed in robust contact with their primary care physicians. Therefore, ensuring that primary care physicians have the tools to treat such disorders is essential. Antidepressants and specific psychotherapies are both highly effective treatments, but most patients prefer counselling (8). Thus it would be sensible to provide family physicians with the best counselling methods (for example, specific psychotherapy) for treating psychiatric illnesses. Of the various psychotherapy treatment models, cognitive-behavioural therapy (CBT) is an empirically supported treatment that plays a well-defined, evidence-based role in the treatment of mood and anxiety disorders (9). CBT, a highly structured, symptom-focused, short-term model of psychotherapy, is perhaps the most rigorously researched form of psychotherapy. Numerous studies in the past 20 years have established CBT’s efficacy in the treatment of anxiety disorders and depression (10–15), in terms of both acute episode treatment and relapse prevention. Despite these developments, a major limitation of CBT is its lack of availability to those who require it (16). This can be partly attributed to a lack of effective dissemination of CBT to mental health professionals, particularly family physicians and psychiatrists, who provide most of the treatment for mood and anxiety disorders. Recent efforts to disseminate CBT have been disappointing. A recent example of this is an evaluation of a basic CBT educational package for general practitioners (GPs) in England, which did not result in GPs’ acquiring sufficient additional expertise to help patients with depression, compared with a control group of doctors (17). As reviewed by Davis and others, effective continuing medical education (CME) requires more than general didactic interventions (18). In addition to attendance at didactic presentations and study of the treatment manual, Craske and others recommend direct supervision of a treatment case as the third component of standard training in empirically supported psychotherapies (19). However, mental health providers in community settings who are interested in learning newer empirically supported treatments often cannot find the necessary supervision or this type of CME training. Thus there is a significant gap between the recommended training and typical CME programs. With this in mind, we designed a more comprehensive training package to include longitudinal supervision of participants’ cases so that mental health professionals can acquire more complex skills in cognitive therapy. This paper describes the design and feasibility of conducting a unique longitudinal supervision course involving 10 sessions of CBT training for a group of mental health practitioners. MethodsCourse Description Consistent with the recommendations of Craske and others (19), participants were required to demonstrate that they had prior exposure to a CBT treatment manual and had attended a significant didactic presentation, defined as a 2-day workshop, before being accepted into the course. Following cardinal CME principles, we conducted a needs survey; matched the learner needs to the training provided; provided the education in an interactive, case-based format; and evaluated the physician’s performance and patient outcomes. The relevance of the case to the practitioner’s actual practice was central to the learner needs. Therefore, all participants were invited to select from their own practice and follow at least one suitable patient who suffered from a depressive and (or) anxiety disorder, using the CBT model. Ideally, patients were selected at the beginning of the course and were followed for at least the duration of the course. Respecting the need for performance feedback and consistent with widely accepted techniques for teaching psychotherapy, we employed the central teaching method of ongoing supervision of therapy mediated by a discussion of audiotaped (and [or] videotaped) psychotherapy sessions. Participants audiotaped (and [or] videotaped) their patient sessions and played these tapes during group supervision. Informed written consent was obtained from all patients to have their tapes played in the supervision sessions. Instructor and peer feedback was provided. Further, to facilitate self-supervision, participants were invited to have their therapy tapes rated by a standardized therapy adherence scale at the beginning and at the end of the course. This allowed participants to assess the reliability of their own adherence ratings. To monitor patient progress and to measure final impact on patients, we used standardized symptom rating scales in every physician–patient encounter. We identified a standardized treatment manual, Cognitive Therapy Basics and Beyond (20), as our key teaching material. We composed a list of 10 course topics based on selected chapters from this manual. The topics included the following: Introduction, Cognitive Conceptualization, Structure of the First Therapy Session, Session Two and Beyond, Structure and Format, Identifying Automatic Thoughts, Responding to Automatic Thoughts, Additional Cognitive and Behavioural Techniques, Homework, Problems in Therapy, and Progressing as a Cognitive Therapist. Each of the 10 sessions consisted of 30 minutes of didactics and demonstrations followed by 90 minutes of group case supervision. Participants convened as one group for the didactic portion, which included a combination of lectures, video demonstrations, and skills modelling. Following the didactic portion, participants split into 2 equal groups for case supervision. To provide a low student-to-supervisor ratio, we used 2 supervisors, both of whom are founding fellows of the Academy of Cognitive Therapy and have advanced training in the teaching of CBT to mental health professionals. The course was offered to mental health providers who are registered to practise in Ontario (that is, psychiatrists, psychologists, family physicians, nurses, and social workers). Participants responded to directed mailings that advertised the courses. We restricted enrollment to 14 participants to ensure a low student-to-supervisor ratio. Evaluation of Participants’ Response to Training Evaluation of Patients’ Symptoms Beck Anxiety Inventory. The Beck Anxiety Inventory (BAI) is a 21-item self-report inventory designed to assess the severity of anxiety in adult psychiatric outpatients (23). A total score ranging from 0 to 63 is obtained by summing across items. It is a widely used measure of anxiety severity, and its reliability and validity are well documented. Clinical Global Impression Scale. The Clinical Global Impression (CGI) scale is an observational scale of global evaluation that is used to assess changes in illness severity in relation to a baseline assessment (24). One item in the scale is used by the clinician to measure the global change of an illness (that is, improvement or worsening) on a 7-point scale ranging from 0 to 6. It can be applied to any type of patient, regardless of the diagnosis. The CGI is a valid, reliable, and widely-used instrument (25). At the beginning of the course, participants were asked, “How much has the patient changed from the time of your initial assessment to the start of the course?” At subsequent visits, participants were asked, “Compared to the patient’s condition at admission to the project, how much has the patient changed?” ResultsRecruitment Therapist Process Outcomes Patient Process Outcomes Preliminary Outcomes Similarly, we report patient outcome data for a limited subset of patients. Paired sample t tests revealed that patients reported lower mean scores on the BDI (mean score before 32.4, SD 11.9 vs mean score after 16.3, SD 14.2; t18 = 6.123, P < 0.001), the BAI (mean score before 28.3, SD 10.9 vs mean score after 15.3, SD 12.9; t14 = 4.914, P < 0.001), and the CGI (mean score before 4.0, SD 1.1 vs mean score after 1.9, SD 0.9; t20 = 7.366, P < 0.001) at the end of the course. Thus patients for whom progress logs were submitted demonstrated significant reductions in symptoms by the end of the course. DiscussionPsychiatric disorders in general and mood and anxiety disorders such as major depression, specifically, remain notoriously undertreated. CBT is a highly effective treatment that is consistent with patient preferences, but it is poorly disseminated. We report here the successful design and implementation of a longitudinal supervision course based on the direct application of cardinal CME principles. Participants had some exposure to didactic CME prior to this event, which according to the Prochaska stages of change model as applied to CME, would not only have provided some knowledge but would also have primed the learner to change his or her behaviour (that is, to adopt a new skill) (26,27). We asked participants to select a patient from their own practice, keeping the learning relevant to their own context and providing an immediate opportunity for exercising skills. Supervision in the form of reviewing audiotapes with both an expert commentator (that is, a faculty member) and peer commentary provided an ideal blend of feedback. The longitudinal nature of the course, with the duration of the education roughly matching the duration of patient treatment, also provided helpful and timely information on skill mastery and problem solving. Consistent with best scientific practices, we used published manuals of “best treatment.” Davis and others cite all these variables as essential to the design of effective CME interventions (18). A unique aspect of this course was the use of standardized rating scales and instruments to measure therapist and patient progress. Most participants submitted tapes to be rated as well as patient progress logs. Thus these evaluation methods show promise as a way of assessing both therapist skill acquisition and patient progress in the context of a CME course. These results justify a more rigorous evaluation of the course effectiveness; for example, evaluation might include comparing this course withn more traditional CME formats. However, participant compliance with submitting tapes and patient progress logs first needs to be improved. Making the receipt of continuing education credits contingent on the submission of these materials has resulted in a significant increase in compliance in a similarly designed course. Without higher compliance, it is possible that only those participants who felt they were improving were comfortable enough to submit audiotapes for both ratings. Those who chose not to submit tapes may have been less motivated and (or) less confident than the subgroup that did. Further, a patient control group would need to be included in future research to rule out potential confounding variables, such as the use of pharmacotherapy. A possible solution would be for course participants to randomly allocate 1 of 2 patients to CBT, with the other patient receiving usual care. Finally, the findings of this study are potentially limited, as course participation was restricted to those with previous CBT training. These participants may represent a self-selected group of mental health practitioners who are highly motivated to seek out additional psychotherapy training. Thus they may be more likely to comply with the unique assessment requirements of this course than would a group of randomly selected clinicians. ConclusionsThis course shows promise as an effective way to teach complex skills in CBT to mental health providers. In limited samples, the course showed clear improvement of therapist adherence to CBT and patient clinical outcomes. With further improvements in data collection and less stringent participant inclusion criteria, an effectiveness study with a matched patient control group would be an important next step. Such a step would help demonstrate to primary care providers and others the potential of this CME intervention to be of significant clinical benefit to patients with mood and anxiety disorders. References1. Offord D, Boyle M, Campbell D, Goering P, Lin E, Wong M, and others. Ontario Health Survey, Mental Health Supplement. Ontario Ministry of Health. Toronto: Queen’s Printer for Ontario; 1994. 2. Robins LH, Locke BA, Regier DA. An overview of psychiatric disorders in America. In: LN Robins, DA Regier, editors. Psychiatric disorders in America: the Epidemiological Catchment Area study. New York: Free Press; 1991. 3. Parikh SV, Lam RW, Enns M, Kennedy SH, Kutcher SP, Ravindran A, and others Dl: clinical guidelines for the treatment of depressive disorders: I. Definitions, prevalence, and health burden. Can J Psychiatry 2001;46(Suppl 1):S13–S20. 4. Mintz J, Mintz LI, Arruda MG, Hwang SS. Treatments of depression and the functional capacity to work. Arch Gen Psychiatry 1992;49:761–8. 5. Parikh SV, Lin E, Lesage AD. Mental health treatment in Ontario: selected comparisons between the primary care and specialty sectors. Can J Psychiatry 1997;42:929–34. 6. Parikh SV, Lesage AD, Kennedy SH, Goering PN. Depression in Ontario: under-treatment and factors associated with antidepressant use. J Affect Disord 1999;52(1–3):67–76. 7. Wagner EH. Meeting the needs of chronically ill people. BMJ 2001;323:945–6. 8. Dwight-Johnson M, Sherbourne CD, Liao D, Wells KB. Treatment preferences among depressed primary care patients. J Gen Intern Med 2000;15:527–34. 9. DeRubeis RJ, Crits-Cristoph P. Empirically supported individual and group psychological treatments for adult mental disorders. J Consult Clin Psychol 1998;66:37–52. 10. Antony MM, Swinson RP. Anxiety disorders and their treatment: a critical review of the evidence-based literature. Ottawa: Health Canada; 1996. 11. Barlow DH, Gorman JM, Shear MK, Woods SW. Cognitive-behavioral therapy, imipramine, or their combination for panic disorder: a randomized controlled trial. JAMA 2000;283:2529–36. 12. Dobson KS. A meta-analysis of the efficacy of cognitive therapy for depression. J Consult Clin Psychol 1999;57:414–9. 13. Hollon SD, Shelton RC, Loosen PT. Cognitive therapy and pharmacotherapy for depression. J Consult Clin Psychol 1991;59:88–99. 14. Segal ZV, Whitney D, Lam RW, CANMAT Depression Work Group. Clinical guidelines for the treatment of depressive disorders: III. Psychotherapy. Can J Psychiatry 2001;46(Suppl 1):29S–37S. 15. Segal ZV, Kennedy SH, Cohen NL, CANMAT Depression Work Group. Clinical guidelines for the treatment of depressive disorders: V. Combining psychotherapy and pharmacotherapy. Can J Psychiatry 2001;46(Suppl 1):59S–62S. 16. Barlow DH, Levitt JT, Bufka, LF. The dissemination of empirically supported treatments: a view to the future. Behavior Research and Therapy 1999;37:S147–S162. 17. King M, Davidson O, Taylor F, Haines A, Sharp D, Turner R. Effectiveness of teaching general practitioners skills in brief cognitive therapy to treat patients with depression: randomised controlled trial. BMJ 2002;321:947–53. 18. Davis D, Thomson MA, Freemantle N, Wolf FM, Mazmanian P, Taylor-Vaisey A. Impact of formal continuing medical education: do conferences, workshops, rounds, and other traditional continuing education activities change physician behavior or health care outcomes? JAMA 1999;282:867–74. 19. Craske MG, Meadows E, Barlow DH. Therapist’s guide for the mastery of your anxiety and panic II and agoraphobia supplement. New York: Graywind; 1994. 20. Beck JS. Cognitive therapy: basics and beyond. New York: Guilford; 1995. 21. Vallis TM, Shaw BF, Dobson KS. The cognitive therapy scale: psychometric properties. J Consult Clin Psychol 1986;54:381–5. 22. Beck AT, Steer RA, Brown GK. Beck Depression Inventory. 2nd ed manual. San Antonio (TX): The Psychological Corporation; 1996. 23. Beck AT, Epstein N, Brown G, Steer RA. An inventory for measuring clinical anxiety: psychometric properties. J Consult Clin Psychol 1988;56:893–7. 24. Guy W. Early Clinical Drug Evaluation Unit (ECDEU) Assessment manual for psychopharmacology. Revised. NIMH publication DHEW nr 76–338. Bethesda (MD): National Institute of Mental Health; 1976. p 217–22. 25. Bech P, Malt UF, Dencker SJ, Ahlfors UG, Elgen K, Lewander T, and others. Scales for assessment of diagnosis and severity of mental disorders. Acta Psychiatr Scand 1993;87:372. 26. Parker K, Parikh SV. Application of Prochaska’s transtheoretical model of change to CME: from assessment of needs to evaluation. Annals of the Royal College of Physicians and Surgeons 1999;32(2):97–9. 27. Parker K, Parikh SV. Applying Prochaska’s model of change to needs assessment, program planning, and outcome measurement. J Eval Clin Pract 2001;7:365–71. Author(s)Manuscript received June 2003, revised, and accepted June 2004. 1. Deputy Head, Cognitive Behaviour Therapy Unit, Department of Psychiatry, Centre for Addition and Mental Health, University of Toronto, Toronto, Ontario. 2. Director, Toronto Center for Cognitive Therapy, Toronto, Ontario. 3. Director of Continuing Mental Health Education, Department of Psychiatry, University Health Network and Centre for Addiction and Mental Health, University of Toronto, Toronto, Ontario. Address for correspondence: Dr MA Lau, Centre for Addiction and Mental Health, 250 College Street, Toronto, ON, M5T 1R8 e-mail: mark_lau@camh.net
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