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 &lsquo;current practice&rsquo;. 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 (&lsquo;equity&rsquo;; &lsquo;strength of evidence&rsquo;, &lsquo;feasibility&rsquo; and &lsquo;acceptability to stakeholders&rsquo;) 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&ndash;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 costeffective intervention for MDD in children and adolescents at A$9000 per DALY saved (95$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 (&gt; 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 mosteffective 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 &lsquo;start-up&rsquo; costs and attention to ensuring an adequate workforce.<br /

Do Children\u27s Advocacy Centers improve families’ experiences of child sexual abuse investigations?

Abstract Objective The Children\u27s Advocacy Center (CAC) model of child abuse investigation is designed to be more child and family-friendly than traditional methods, but there have been no rigorous studies of their effect on children\u27s and caregivers’ experience. Data collected as part of the Multi-Site Evaluation of Children\u27s Advocacy Centers were used to examine whether CACs improve caregivers’ and children\u27s satisfaction with investigations. Methods Nonoffending caregiver and child satisfaction were assessed during research interviews, including the administration of a 14-item Investigation Satisfaction Scale (ISS) for caregivers. Two hundred and twenty-nine sexual abuse cases investigated through a CAC were compared to 55 cases investigated in communities with no CAC. Results Hierarchical linear regression results indicated that caregivers in CAC cases were more satisfied with the investigation than those from comparison sites, even after controlling for a number of relevant variables. There were few differences between CAC and comparison samples on children\u27s satisfaction. Children described moderate to high satisfaction with the investigation, while a minority expressed concerns about their experience. Conclusions The CAC model shows promise for improving families’ experiences, but to build upon this promise, agencies will need to systematize procedures for refining and adapting the model as new research becomes available

Training of child and adolescent psychiatry fellows in autism and intellectual disability

Patients with autism spectrum disorders and intellectual disability can be clinically complex and often have limited access to psychiatric care. Because little is known about post-graduate clinical education in autism spectrum disorder and intellectual disability, we surveyed training directors of child and adolescent psychiatry fellowship programs. On average, child and adolescent psychiatry directors reported lectures of 3 and 4 h per year in autism spectrum disorder and intellectual disability, respectively. Training directors commonly reported that trainees see 1-5 patients with autism spectrum disorder or intellectual disability per year for outpatient pharmacological management and inpatient treatment. Overall, 43% of directors endorsed the need for additional resources for training in autism spectrum disorder and intellectual disability, which, coupled with low didactic and clinical exposure, suggests that current training is inadequate

Supporting Japanese mothers of children with ADHD: cultural adaptation of the New Forest Parent Training Programme

International practice guidelines recommend medication and behavioral intervention as evidenced-based treatments for attention deficit hyperactivity disorder (ADHD). Currently in Japan, the availability of non pharmacological interventions for ADHD is limited. We report the results of a pilot and a proof-of-concept study for a new behavioral intervention for Japanese mothers of children with ADHD. The pilot study delivered a standard six-session behavioral intervention and two parent-support sessions. Participants approved the group format and requested additional support to change parenting practices and behavioral strategies targeting ADHD symptoms. For the proof-of-concept study, the intervention was revised to include five sessions of pre intervention support followed by six sessions of the New Forest Parent Training Programme (NFPP), an evidence based intervention for ADHD. The revised intervention, NFPP-Japan, was associated with reductions in the mothers’ reports of children's ADHD symptoms and aggression, more effective parenting practices, and reduced parenting stress. The pilot and proof-of-concept studies indicate that it is possible to successfully modify Western behavioral interventions for Japanese mothers and to justify a randomized controlled trial evaluation of the NFPP-Japan, which is currently underway

Adolescent Suicide Risk Screening in the Emergency Department

Many adolescents who die by suicide have never obtained mental health services. In response to this, the National Strategy for Suicide Prevention recommends screening for elevated suicide risk in emergency departments (EDs). This cross-sectional study was designed to examine 1) the concurrent validity and utility of an adolescent suicide risk screen for use in general medical EDs and 2) the prevalence of positive screens for adolescent males and females using two different sets of screening criteria.Participants were 298 adolescents seeking pediatric or psychiatric emergency services (50% male; 83% white, 16% black or African American, 5.4% Hispanic). The inclusion criterion was age 13 to 17 years. Exclusion criteria were severe cognitive impairment, no parent or legal guardian present to provide consent, or abnormal vital signs. Parent or guardian consent and adolescent assent were obtained for 61% of consecutively eligible adolescents. Elevated risk was defined as 1) Suicidal Ideation Questionnaire-Junior [SIQ-JR] score of ≥31 or suicide attempt in the past 3 months or 2) alcohol abuse plus depression (Alcohol Use Disorders Identification Test-3 [AUDIT-3] score of ≥3, Reynolds Adolescent Depression Scale-2 [RADS-2] score of ≥76). The Beck Hopelessness Scale (BHS) and Problem Oriented Screening Instrument for Teenagers (POSIT) were used to ascertain concurrent validity.Sixteen percent ( n =  48) of adolescents screened positive for elevated suicide risk. Within this group, 98% reported severe suicide ideation or a recent suicide attempt (46% attempt and ideation, 10% attempt only, 42% ideation only) and 27% reported alcohol abuse and depression. Nineteen percent of adolescents who screened positive presented for nonpsychiatric reasons. One-third of adolescents with positive screens were not receiving any mental health or substance use treatment. Demonstrating concurrent validity, the BHS scores of adolescents with positive screens and the POSIT scores of those with positive screens due to alcohol abuse and depression indicated substantial impairment. The addition of alcohol abuse with co-occurring depression as a positive screen criterion did not result in improved case identification. Among the subgroup screening positive due to depression plus alcohol abuse, all but one (>90%) also reported severe suicide ideation and/or a recent suicide attempt. This subgroup (approximately 17% of adolescents who screened positive) also reported significantly more impulsivity than other adolescents who screened positive.The suicide risk screen showed evidence of concurrent validity. It also demonstrated utility in identifying 1) adolescents at elevated risk for suicide who presented to the ED with unrelated medical concerns and 2) a subgroup of adolescents who may be at highly elevated risk for suicide due to the combination of depression, alcohol abuse, suicidality, and impulsivity.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/78701/1/j.1553-2712.2009.00500.x.pd

The effect of a training programme on school nurses’ knowledge, attitudes, and depression recognition skills: The QUEST cluster randomised controlled trial

Background Mental health problems in children and young people are a vital public health issue. Only 25% of British school children with diagnosed mental health problems have specialist mental health services contact; front-line staff such as school nurses play a vital role in identifying and managing these problems, and accessing additional services for children, but there appears limited specific training and support for this aspect of their role. Objectives To evaluate the effectiveness of a bespoke short training programme, which incorporated interactive and didactic teaching with printed and electronic resources. Hypothesized outcomes were improvements in school nurses’ knowledge, attitudes, and recognition skills for depression. Design A cluster-randomised controlled trial. Participants and setting 146 school nurses from 13 Primary Care Trusts (PCTs) in London were randomly allocated to receive the training programme. Methods School nurses from 7 PCTs (n = 81) were randomly allocated to receive the training intervention and from 6 PCTs (n = 65) for waiting list control. Depression detection was measured by response to vignettes, attitudes measured with the Depression Attitude Questionnaire, and knowledge by the QUEST knowledge measure. These outcomes were measured at baseline and (following training) 3 months and nine months later, after which nurses in the control group received the training programme. Results At 3 months, 115 nurses completed outcome measures. Training was associated with significant improvements in the specificity of depression judgements (52.0% for the intervention group and 47.2% for the control group, P = 0.039), and there was a non-significant increase in sensitivity (64.5% compared to 61.5% P = 0.25). Nurses’ knowledge about depression improved (standardised mean difference = 0.97 [95% CI 0.58 to 1.35], P < 0.001); and confidence about their professional role in relation to depression increased. There was also a significant change in optimism about depression outcomes, but no change in tendency to defer depression management to specialists. At 9-month follow-up, improved specificity in depression identification and improved knowledge were maintained. Conclusions This school nurse development programme, designed to convey best practice for the identification and care of depression, delivered significant improvements in some aspects of depression recognition and understanding, and was associated with increased confidence in working with young people experiencing mental health problems