022 Comparative Effectiveness of Counselling Providers With Different Qualifications

1of14 Report#091322.34R1CounsellingEvidenceReview

TransportAccidentCommission&WorkSafeVictoria

Evidence Service

Comparative effectiveness of counselling providers with different qualifications

August 2013

Plain Language Summary Aftertrauma(e.g.acarcrashorinjury),peoplecanhavelonglastingmentalhealthproblems,likeanxietyordepression.Counsellorstrytohelpthesepeoplecopebetter.Counsellorscanhavedifferenttypesoftraining.Thereisnotenoughresearchtotellifthetypeoftrainingeffectspatientcare.



Evidence Service Comparative effectiveness of counselling providers with different qualifications

August 2013

Executive Summary Background

Peopleaffectedbytraumacanexperienceongoingmentalhealthsymptoms.Counsellingisoneformoftreatmentthataimstohelppeoplebettercopewiththeirexperienceoftraumaandtheresultingsymptoms.Counsellingproviderscanvaryconsiderablyintheirleveloftraining.Thisreportsoughttoreviewtheevidencethatcomparestheeffectivenessofcounsellingproviderswithdifferentqualifications.Onehighqualitysystematicreviewoffiverandomisedcontrolledtrialswasfoundandusedasthebasisofthisreport.

Does the qualification of the counselling provider effect outcomes for people after trauma?

Thereviewfoundthatthesmallnumberofstudiesavailabledoesnotallowconclusionstobedrawnabouttheeffectsofprofessionalcounsellingproviderscomparedtoparaprofessionalcounsellingprovidersformentalhealthoutcomesinpeoplefollowingtrauma.

Glossary Professionalcounsellingproviders

Peoplewithspecialisedprofessionaltrainingforthetreatmentofanxietyanddepression,includingpsychiatristsandpsychologists.Nursesandcounsellorsmaybeincludedinthisgroupifspecialistmentalhealthtrainingwasacompulsorypartoftheirdegree.

Paraprofessionalcounsellingproviders

Mentalhealthcareworkers,paidorvoluntary,whowereunqualifiedwithrespecttopsychologicaltreatmentforanxietyanddepressivedisorders.



Evidence Service

Comparative effectiveness of counselling providers with different qualifications Evidence Review

August 2013 Emma Donoghue, Natasha Dodge


CONTENTS

ACKNOWLDEGEMENTS............................................................................................................................4BACKGROUND..........................................................................................................................................5METHODS.................................................................................................................................................6RESULTS...................................................................................................................................................7DISCUSSION..............................................................................................................................................9CONCLUSION............................................................................................................................................9SUMMARYTABLES.................................................................................................................................10DISCLAIMER............................................................................................................................................12CONFLICTOFINTEREST..........................................................................................................................13REFERENCES...........................................................................................................................................14

ACKNOWLDEGEMENTS

TheauthorswouldliketothankFionaChomley,LaurenMcKirdy,KarenTait,JaneReidandGulsunAlifortheirassistancewithscopingofthetopicforthisreport.


BACKGROUND

Trauma and mental health

Followingtraumaticevents,psychologicaldistressiscommon.1Traumatisedpeoplecanexperienceemotionalupset,increasedanxiety,sleepandappetitedisturbance,oradditionalreactionssuchasfear,sadness,guiltoranger.1Oftenthepsychologicalsymptomsofdistresssubsideinthedaysandweeksfollowingthetraumaticevent,howeverforsomepeoplethesesymptomspersistanddevelopintolongerlastingproblems.1Motorvehicleaccidentsarecommonlyassociatedwithanxiety,depressionandposttraumaticstressdisorder(PTSD).2Similarly,peopleinjuredintheworkplacecansufferpsychologicaldistress(suchasanxiety,depressionandPTSD),sometimestoagreaterdegreethanthoseinjuredoutsidetheworkplace.3Eachyear,around20%ofAustraliansaged1685(aroundthreemillionpeople)experiencesymptomsofamentalhealthdisorder(suchasdepression;anxietyorasubstanceusedisorder).4In20102011,thestateofVictoriahadthehighestnumberofpatientsandMedicaresubsidisedmentalhealthservices,amongallStatesandTerritories.4,5InAustralia,mentalhealthdisordersareoftenmanagedbygeneralpractitioners(GPs).4In20102011,themostcommonwaysthatGPsmanagedpatientspresentingwithmentalhealthproblemswasusingoneoracombinationof:medication,provisionofadviceorcounselling,andreferralforspecialisedmentalhealthcare.4,5Counselling and qualifications

Counsellingisoneinterventionthataimstohelppeoplebettercopewithdifficultlifecircumstancessuchas:griefandloss;communicationandrelationships;workandcareer;stress,anxietyanddepression;lifetransitions;parenting;selfesteem;spirituality;anddifficultiescausedbyaddictions,traumaandabuse.6InAustraliathereisnolegislativerecognitionofcounsellingasadistinctprofessionandtherearenoregulationstogoverntheuseofthetermcounsellor,asisthecaseforregulatedprofessionssuchaspsychologyandsocialwork.7Counsellingpractitionersaregenerallydrawnfromdiverseprofessionalandtheoreticalbackgrounds,withvaryinglevelsoftrainingrangingfromdoctorallevelthroughtodiplomasofoneyearorless.7AlthoughpeakbodiessuchasthePsychotherapyandCounsellingFederationofAustraliaprovidesasetoftrainingstandardsformembership,counsellorsarenotrequiredtoregisterinordertopractice.7CounsellingissubsidisedthroughtheAustralianMedicareBenefitsSchedule(MBS),butonlyifitisprovidedbypsychiatrists,psychologists,andsomealliedhealthprofessionals(specifically,socialworkers,mentalhealthnursesandoccupationaltherapists).4


Intended purpose of the review

TheTransportAccidentCommission(TAC)andWorkSafeVictoria(WSV)requestedareviewoftheevidencetocomparetheeffectivenessofcounsellingproviderswithdifferentqualifications.Thisreportsoughttoanswerthefollowingquestion:

Doesthequalificationofthecounsellingprovidereffectoutcomesforpeopleaftertrauma?

METHODS

Methodsareoutlinedbrieflybelow.MoredetailedinformationaboutthemethodologyusedtoproducethisreportisavailableinAppendices1and2.AllappendicesarelocatedintheTechnicalReportaccompanyingthisdocument.Stage 1: Identify relevant research

AcomprehensivesearchofMedline,PsycINFO,CINAHL,EMBASEandtheCochraneLibrarywasundertakeninJune2013toidentifyrelevantsynthesisedresearch(systematicreviews(SRs)),andanyrelevantprimarystudies(randomisedcontrolledtrials(RCTs)orcontrolledclinicaltrials(CCTs)).SearchesoftheMotorAccidentsAuthorityofNSW(www.maa.nsw.gov.au)andtheAccidentCompensationCorporation(ACC)ofNewZealand(www.acc.co.nz)websiteswerealsoundertaken.Referencelistsofincludedstudieswerealsoscannedtoidentifyrelevantreferences.Studiesidentifiedbythesearcheswerescreenedforinclusionusingspecificselectioncriteria(seeAppendix2,TableA2.1).InthisreviewstudieswereonlyincludediftheywereSRs,RCTsorCCTsthatinvestigatedtheeffectsofcounsellingdeliveredbyprofessionalcomparedwithcounsellingdeliveredbyparaprofessionalsinpeopleexperiencingmentalhealthissuesrelatedtotrauma.Systematicreviewsthatmettheselectioncriteriawerereviewedtoidentifythemostuptodateandcomprehensivesourceofevidenceandcriticallyappraisedtodeterminewhethertheywereofhighquality.Thisprocesswasrepeatedforadditionalsourcesofevidence,untilthemostrecent,comprehensiveandhighqualitysourceofevidencewasidentifiedforeachindication.Allscreeningandselectionwasconductedindependentlybytworeviewers,resultswerecomparedandanydiscrepanciesdiscussedandresolved.Stage 2: Address further actions identified

SeealgorithminTable1.Table 1. Further action required to answer clinical questions.

Is there any synthesised research available? (e.g. EBGs, HTAs, SRs)

Yes No

Is this good quality research? Are RCTs available?

Yes No Yes No

Is it current (within 2 years)?

Undertake new SR and/or metaanalysis

Undertake new SR and/or metaanalysis

Consider looking for lower levels of evidence

Yes No

No further action Update existing SR


Themostrecent,relevant,highqualitypieceofevidencewasusedtoaddressthequestionposedabove.

RESULTS

Databasesearchesyielded3,728articles,whichwerescreenedforpotentialrelevance.Ofthese,29articleswerereviewedinfulltext.Fromthisreviewtwoarticleswereidentified(seeAppendices3and4).Nofurtherstudieswereidentifiedfromtheresultsoftheinternetsearch.Intotal,2paperswereidentified,consistingof:

1synthesisedstudy(1SR)8 1primarystudy(1RCT),9whichwasincludedinthesystematicreviewabove

ThisreportisthereforebasedonthesystematicreviewbyBoer(2005).8Criticalappraisalofthereviewfoundittobeofhighquality(seeAppendix5).TheSRbyBoer(2005)8aimedtocriticallyexaminethecommonsensenotionthatprofessionaltraining/qualificationisnecessarytodelivereffectivepsychologicaltreatmentforanxietyanddepressivedisorders.ThereviewonlyincludedRCTsthatlookedat:

1. paraprofessionaldeliveryofpsychologicaltreatmentforanxietyanddepressionversusprofessionaldeliveryoftreatment,or

2. paraprofessionaldeliveryofpsychologicaltreatmentforanxietyanddepressionversusnotreatment

Thelattercomparisonhoweverwasnotthefocusofthisreportandthustheseresultswereonlydiscussedbriefly.Inthisreviewtheauthorsdefinedprofessionalsaspeoplewithspecialisedprofessionaltrainingforthetreatmentofanxietyanddepression,includingpsychiatristsandpsychologists.Nursesandcounsellorswerealsoincludedinthisgroupifspecialistmentalhealthtrainingwasacompulsorypartoftheirdegree.Paraprofessionalswerementalhealthcareworkers,paidorvoluntary,whowereunqualifiedwithrespecttopsychologicaltreatmentforanxietyanddepressivedisorders.StudiesinthisreviewwerescoredagainstaQualityRatingScale(QRS),developedbytheCochraneCollaborationDepression,AnxietyandNeurosisReviewGroups.TheQRSwasdevelopedinordertostandardisethequalityassessmentoftrials,assessing23itemsofqualityaccordingtothreedegreesofadequacy(0;1;2).Inthisreviewstudieswerescoredagainst21ofthe23qualityitems,excludingtheblindingandsideeffectsitems,whichwerenotrelevanttothesetrials.Themaximumscorethatcouldberetrievedwas42for21items. ThereviewanditsfiveincludedstudiesaresummarisedinTables2and3.


Study characteristics

ThestudiesincludedintheBoerSR8werepublishedbetween1976and2003.Thepopulationsoftheincludedstudiesvaried.Twostudieslookedatanxiety:anxiousfirsttimemothers,10andspeechanxiety.11Theotherthreestudieslookedatvarioustypesofdepression,9,12andwomenatriskofdevelopingpostpartumdepression.13Theinterventionsexaminedbythestudiesalsovariedandincluded:cognitivebehaviouraltherapy9;supportivegrouptherapy;9systematicdesensitisationrelaxationandcuecontrolledrelaxation;11socialworkersupport;10andpeersupport.12,13Threeofthestudiesexaminedinterventionsforindividuals,10,12,13andtwolookedatgrouptherapies.9,11Alloftheparaprofessionalinterventionsinvolvedtrainingofvaryingduration.Oneoftheincludedstudiescomparedthesameinterventiondeliveredbyprofessionalsandparaprofessionals,9onestudycomparedthesameinterventiondeliveredbyprofessionalsandparaprofessionalsandnotreatment,11onestudycompareddifferentinterventionsdeliveredbyprofessionalsandparaprofessionalsandnotreatment,10whiletheremainingtwostudiescomparedparaprofessionalinterventionswithacontrolcondition(usualcommunitycare,13andnotreatment12).Thedurationoftreatmentintheincludedstudieswassixweeksforonestudy,11tenweeksforanotherstudy,9andnotspecifiedfortheremainingthreestudies.10,12,13Theincludedstudiesalsovariedintheoutcomemeasuresusedandthelengthoffollowup:

SpielbergerStateAnxiety,CostelloComreyAnxietyandTraitDepressionScales,BeckDepressionInventory(measuredat12months)10

HamiltonRatingScaleforDepression;BeckDepressionInventory(measuredtenweeksposttreatment)9

EdinburghPostnatalDepressionScalescore>12(measuredateightweeks)13 PresentStateExamination(measuredafteroneyear)12 TaylorManifestAnxietyScale(measuredsixweeksposttreatment)11

Study quality

Fourofthefiveincludedstudieswereconsideredtobeofmoderatetohighquality,i.e.QRSscorebetween2142.9,10,12,13ThestudybyRussell(1976)11wasconsideredtobeoflowquality.Thesamplesizewassmallforalloftheincludedstudies,withlessthan50ineacharm.Allocationconcealmentwasadequatelyperformedinthreeofthestudies10,12,13anddetailedbaselinecharacteristicswereonlyreportedbyonestudy.13Furthermorepowercalculationswereonlyadequatelyperformedandreportedinonestudy.9Clearselectioncriteriawerereportedinfourofthestudies.9,10,12,13Blindingofparticipantsandoutcomeassessorswasnotperformedinanyofthestudies.

Study results

Theindividualstudiesandtheirpooledresultsfoundnosignificantdifferencebetween


paraprofessionalsandprofessionalswithregardstoreductioninsymptomseverityimmediatelyfollowingtreatment911(StandardMeanDifference(SMD)=0.09,95%CI0.23to0.40;p=0.58)oratthree,six,nineand12monthsfollowup.11Furthermorenoheterogeneitywasfoundbetweenstudies(I2=0.1%;Chi2=4.0;df=4;p=0.41).Inadditionnosignificantdifferencewasfoundbetweenprofessionalsandparaprofessionalsfollowingvarioussensitivityandsubgroupanalyses(e.g.,studyquality,outcomemeasures,inclusioncriteria;paraprofessionalbackground,indication(anxietyordepression),individualorgroupinterventionorwhetherprofessionalsandparaprofessionalsperformedthesameintervention).Asignificantdifferencewasfoundinfavourofparaprofessionalscomparedtoacontrolcondition;1013howeverthiswasnotthefocusofthisreport.

DISCUSSION

Theauthorsconcludethatthefindingsofthereviewareinconclusivewithregardstoparaprofessionalspartiallyreplacingprofessionalsinthetreatmentofanxietyanddepressivedisordersduetothesmallnumberofincludedstudies,theirsmallsamplesizes,variationsintreatmentduration,majorityfemalepopulation,andmethodologicallimitations(suchasthepotentialraterbiasarisingfromtheuseofselfratedmeasuresandlackofblindingforobserverratedmeasures).8Theauthorssuggestthatthelackofasignificantdifferencebetweenparaprofessionalsandprofessionalscouldbeduetotheincludedstudiesbeinginadequatelydesignedtodetectsignificantdifferences.8ItshouldalsobenotedthatthemajorityofthestudiesincludedintheSRareovertenyearsold,withtheoldestpublishedin1976andthemostrecentpublishedin2003.

CONCLUSION

Thesmallnumberofstudiesavailabledoesnotallowconclusionstobedrawnabouttheeffectsofprofessionalcounsellingproviderscomparedtoparaprofessionalcounsellingprovidersformentalhealthoutcomesforpeoplefollowingtrauma.


SUMMARY TABLES Table 2. Summary of Boer 2005.8 BoerPC,WiersmaD,RussoS,vandenBoschRJ.Paraprofessionalsforanxietyanddepressivedisorders.Cochranedatabaseofsystematicreviews(Online).2005(2):CD004688.Studytype Systematicreviewof5RCTsIndication AnxietyanddepressivedisordersOutcomes Depressionand/oranxietysymptomscalescores.Validatedobserverand

selfratedmeasurementscaleswereaccepted.Definitionofprofessionals Peoplewithspecialisedprofessionaltrainingforthetreatmentofanxiety

anddepression,includingpsychiatristsandpsychologists.Nursesandcounsellorswereonlyincludedinthisgroupifspecialisttrainingwasacompulsorypartoftheirdegree.

Definitionofparaprofessionals Mentalhealthcareworkers,paidorvoluntary,whowereunqualifiedwithrespecttopsychologicaltreatmentforanxietyanddepressivedisorders.

Typeofintervention AnykindofpsychologicaltreatmentforanxietyanddepressivedisordersComparisonsmade 1.Paraprofessionalsvs.professionals

2.Paraprofessionalsvs.controlIncludedstudies 5RCTs:Barnett1985,10 Bright1999,9 Dennis2003,13Harris1999,12Russell

197611Findings Main results

Fivestudiesreportedfivecomparisonsofparaprofessionalsversusprofessionals(n=106)andfivecomparisonsofparaprofessionalsversuscontrolcondition(n=220).Nodifferenceswerefoundbetweenparaprofessionalsandprofessionals(SMD=0.09,95%CI0.23to0.40,p=0.58),andnosignificantheterogeneity.Studiescomparingparaprofessionalsversuscontrol(mixedcontinuousanddichotomousdata)showedasignificanteffectinfavourofparaprofessionals(OR=0.34,95%CI0.13to0.88,p=0.03),butheterogeneitywasindicated(I=60.9%,Chi=10.24,df=4,p=0.04).Authors conclusions Thefewstudiesincludedinthereviewdidnotallowconclusionsabouttheeffectofparaprofessionalscomparedtoprofessionals,butthreestudies(womenonly)indicatedasignificanteffectforparaprofessionals(allvolunteers)comparedtonotreatment,however,thisfindingisnotspecifictocounsellingasanintervention.Theevidencetodatemayjustifythedevelopmentandevaluationofprogramsincorporatingparaprofessionalsintreatmentprogramsforanxietyanddepressivedisorders.


Table 3. Summary of studies included in Boer 2005.8 Barnett 198510(RCT) Population:89highlyanxiousfirsttimemothers,3or4dayspostpartumSetting:hospital,AustraliaProfessionalintervention:assistancefromsocialworkerParaprofessionalintervention:assistancefromvolunteerControlgroup:notreceivinganyintervention.Treatmentduration:notspecifiedFollowup:Assessmentsatthree,six,nineandtwelvemonths.Outcomes&measures:Primaryoutcomewasstateanxietylevelat12months.SpielbergerStateAnxiety;Costellocomreyanxietyandtraitdepressionscales;TheBeckDepressionInventory.Quality:Interviewerofinitialinterviewandassessmentwasblinded.Nobaselinedifferencesoftrialsubjectsbetweenallocatedgroups.Nocointerventionsorotherpotentialconfounders.Adequateallocationconcealment.Qualityratingsystemscore:23Bright 19999(RCT) Population:98peoplewithdepression(28male,70female)Setting:universitybasedclinic,USAProfessionalIntervention:cognitivebehaviouraltherapy(CBT)ormutualsupportivegrouptherapyprovidedbyprofessionals(mastersdegreeinclinicaltraininginclinicalorcounsellingpsychology)ParaprofessionalIntervention:CBTormutualsupportivegrouptherapyprovidedbyparaprofessionals(noformaltraining,recruitedfromcommunitybasedselfhelporganizations)Treatmentduration:10weektreatmentduration;weekly90minsessionsforbothtreatmentconditionsFollowup:10weeksposttreatmentassessmentOutcomes&measures:10weeksposttreatment,HamiltonRatingScaleforDepressionassessedbyanindependentclinician;BeckDepressionInventory.Quality:Patient,providerandoutcomeassessorblindingwerenotmentioned.Dropoutratebeforecompleting7sessions=30%,42completedtheposttreatmentassessment.Baselinecharacteristicsdifferencesbetweencomparisongroupsnotreported.Allocationconcealment?Unclear.Nocointerventionsorotherpotentialconfounders.Qualityratingsystemscore:30.Dennis 200313(RCT) Population:44mothersidentifiedashighriskforpostpartumdepression(812weekspostpartum)Setting:home(telephonebased),CanadaParaprofessionalintervention:telephonebasedpeersupport(mothertomother),fromamotherwhopreviouslyexperiencedpostpartumdepressionControlgroup:usualcare(bothgroupshadaccesstothestandardcommunitypostpartumservices)Treatmentduration:telephonesupportprovidedasoftenasthepatientdeemednecessary,durationnotspecifiedFollowup:Assessmentsat4and8weekspostrandomisation,nolongtermfollowupOutcomes&measures:primaryoutcomeat8weeksEdinburghPostnatalDepressionScalescore>12Quality:Onedropoutinthecontrolgroup.Nobaselinedemographicdifferencesbetweencomparisongroups.


Intentiontotreatanalysis.Communitypostpartumservicesarepotentiallybiasing;nootherpotentialconfounders.Allocationconcealmentadequate.Qualityratingsystemscore:27Harris 199912(RCT) Population:86womenwithchronicdepressionSetting:homebased,UKParaprofessionalintervention:Volunteerbefriendingmeetingandtalkingwiththedepressedwomanforaminimumofonehoureachweek,andactingasafriendtoher,listeningandbeingthereforher.Controlcondition:notreceivingintervention,onwaitlistTreatmentduration:notspecifiedFollowup:Onefinalassessmentafter1yearOutcomes&measures:Remissionoftwomonthsormoreafteroneyear;PresentStateExamination.Quality:Intentiontotreatdesign.Nowithdrawals.Nobaselinedemographicdifferencesbetweencomparisongroups.Cointerventions(professionalcontactorpsychotropicdrugs)butnoassociationwithoutcome;nootherpotentialconfounders.Allocationconcealmentadequate.QualityRatingSystemscore:31Russell 197611(RCT) Population:23males,27females,volunteerundergraduates,withspeechinganxietySetting:university,USAProfessionalIntervention:systematicdesensitisationrelaxationandcuecontrolledrelaxationingroupsof2to4,ledbyprofessionals(counsellorsPhDinpsychology,experiencedwithinterventions).ParaprofessionalIntervention:systematicdesensitisationrelaxationandcuecontrolledrelaxationingroupsof2to4,ledbyparaprofessionals(advancedundergraduatewhohadnoprevioustrainingininterventions).ControlGroup:notreatmentTreatmentduration:5treatmentsessionsover6weeksFollowup:notspecifiedOutcomes&measures:Posttreatmentassessmentof6weeks,TaylorManifestAnxietyScaleQuality:Nopatient,providerandoutcomeassessorblinding.Nobaselinedifferencesbetweenthegroupsonscalesbyanalysisofvariance.Nocointerventionsorotherpotentialconfounders.42completedtheposttreatmentassessment.Allocationconcealmentunclear.QualityRatingsystemscore:17

DISCLAIMER

Theinformationinthisreportisasummaryofthatavailableandisprimarilydesignedtogivereadersastartingpoint to consider currently available research evidence. Whilst appreciable care has been taken in thepreparation of the materials included in this publication, the authors and the National Trauma ResearchInstitutedonotwarrant theaccuracyof thisdocumentanddenyany representation, impliedorexpressed,concerningtheefficacy,appropriatenessorsuitabilityofanytreatmentorproduct.Inviewofthepossibilityofhuman error or advances of medical knowledge the authors and the National Trauma Research Institutecannot and do not warrant that the information contained in these pages is in every aspect accurate orcomplete.Accordingly,theyarenotandwillnotbeheldresponsibleorliableforanyerrorsoromissionsthatmaybefound inthispublication.Youarethereforeencouragedtoconsultothersources inordertoconfirm


the information contained in thispublication and, in theevent thatmedical treatment is required, to takeprofessionalexpertadvicefromalegallyqualifiedandappropriatelyexperiencedmedicalpractitioner.

CONFLICT OF INTEREST

The TAC/WSV Evidence Service is provided by theNational Trauma Research Institute. TheNTRI does notacceptfundingfrompharmaceuticalorbiotechnologycompaniesorothercommercialentitieswithpotentialvestedinterestintheoutcomesofsystematicreviews.The TAC/WSV Health Services Group has engaged the NTRI for their objectivity and independence andrecognises that anymaterialsdevelopedmustbe freeof influence frompartieswith vested interests. TheEvidenceServicehasfulleditorialcontrol.


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022 Comparative Effectiveness of Counselling Providers With Different Qualifications