Does Interpersonal Psychotherapy improve clinical care for adolescents with depression attending a rural child and adolescent mental health service? Study protocol for a cluster randomised feasibility trial

Background: Depression amongst adolescents is a costly societal problem. Little research documents the effectiveness of public mental health services in mapping this problem. Further, it is not clear whether usual care in such services can be improved via clinician training in a relevant evidence based intervention. One such intervention, found to be effective and easily learned amongst novice clinicians, is Interpersonal Psychotherapy (IPT). The study described in the current paper has two main objectives. First, it aims to investigate the impact on clinical care of implementing Interpersonal Psychotherapy for Adolescents for the treatment of adolescent depression within a rural mental health service compared with Treatment as Usual (TAU). The second objective is to record the process and challenges (i.e. feasibility, acceptability, sustainability) associated with implementing and evaluating an evidence-based intervention within a community service. This paper outlines the study rationale and design for this community based research trial.Methods/design: The study involves a cluster randomisation trial to be conducted within a Child and Adolescent Mental Health Service in rural Australia. All clinicians in the service will be invited to participate.&nbsp; Participating clinicians will be randomised via block design at each of four sites to (a) training and delivery of IPT, or (b) TAU. The primary measure of impact on care will be a clinically significant change in depressive&nbsp; symptomatology, with secondary outcomes involving treatment satisfaction and changes in other symptomatology. Participating adolescents with significant depressive symptomatology, aged 12 to 18 years, will complete assessment measures at Weeks 0, 12 and 24 of treatment. They will also complete a depression inventory once a month during that period. This study aims to recruit 60 adolescent participants and their parent/guardian/s. A power analysis is not indicated as an intra-class correlation coefficient will be calculated and used to inform sample size calculations for subsequent large-scale trials. Qualitative data regarding process implementation will be collected quarterly from focus groups with participating clinicians over 18 months, plus phone interviews with participating adolescents and parent/guardians at 12 weeks and 24 weeks of treatment. The focus group qualitative data will be analysed using a Fourth Generation Evaluation methodology that includes a constant comparative cyclic analysis method.Discussion: This study protocol will be informative for researchers and clinicians interested in considering, designing and/or conducting cluster randomised trials within community practice such as mental health services.<br /

Normalising Uncertainty in Undergraduate Clinical Transition Seminars

Background The transition from the pre-clinical to clinical years of undergraduate medical training is a profound experience for medical students, one that is characterised by intense uncertainty and anxiety. The medical education literature tends to focus on dealing with medical uncertainty through teaching effective clinical decision-making skills. The emphasis is placed on developing the instrumental capacities of individual students at the cognitive, technical, conceptual and personal levels. This leads to neglect of the situational and collective social responses that students experience and use when adapting to training within the clinical environmental culture(s). Objectives This paper reports on an evaluation of clinical transition seminars for 4th year Monash MBBS students conducted in July 2003. The seminars were designed and implemented with a dual purpose in mind: to introduce 4th year students to the social aspects of uncertainty in medical training and practice within hospital settings, and to inform the development and implementation of transition seminars for the 3rd year students of the new five-year Monash MBBS curriculum. The key objectives of the teaching and learning activity were to increase the students' understanding of the clinical environment, the complexities inherent in the management of the multiple identities they embody within this context, and the uncertainty that is associated with practising medicine. Method Nine two-hour seminars were conducted over a three-day period involving 180 students in groups of 20. Results: The evaluation results demonstrate that the students believed that the seminars contributed positively to their transition to the hospital environment and that learning activities that account for broader aspects of uncertainty in medicine are highly valued. Conclusions The results suggest that a greater focus on the social aspects of uncertainty within clinical transition teaching regimes is perceived to be beneficial by medical students

The PUC-CAM-Q: A new questionnaire for delving into the use of complementary and alternative medicines

Objective: This paper reports on the design and testing of a new questionnaire, "Perspectives on the Use in Communities of CAM" (the PUC-CAM-Q [questionnaire]). Design: The questionnaire consisted of scales and questions for 27 concepts considered to affect complementary and alternative medicine (CAM) usage. Scales encompassed 13 beliefs about nature, scientific medicine, and the environment, as well as personal characteristics, such as stoicism and resilience. A matrix provided space for respondents to indicate their use, or likelihood of use, of 23 of the most commonly available CAM modalities. Also included were questions about the reasons for CAM use and sources of health information. Location: The questionnaire was mailed to a randomly selected sample of people in a pilot study of two metropolitan and five rural localities in Victoria, Australia. Results: The response rate was 40% (n = 459). The majority of the questionnaires were completed consistently, and the reliability and validity and questions were satisfactory. Seven (7) of the 13 scales that explored the beliefs and concerns about CAM use and the characteristics of the respondents had Cronbach alphas of above 0.7. Refinement of the other six scales resulted in alphas of between 0.6 and 0.7, with good corrected item-total correlations for included questions. Responses to the matrix question on the use, or likelihood of use, of individual CAM modalities were also good. However, some adjustments to the layout would provide more comprehensive information for future use of the PUC-CAM-Q. Conclusions: This questionnaire provided good data that were appropriate for the exploratory nature of this PUC-CAM study. After more attention to the scales, as well as some refinement of some nonscale questions, the PUC-CAM-Q would be a practical instrument for further studies on CAM use

Medical students' and GP registrars' accommodation needs in the rural community: insight from a Victorian study

Medical education in Australia is currently entering a new era, including support for the significant extension of medical students and general practitioner (GP) registrars' training programs in rural communities. This commitment to rural medical student and general practitioner recruitment and retention has made the provision of accommodation in rural communities a vital issue. This study has found that approximately half of all medical students on placement with rural GPs are currently accommodated with their GP supervisor or with other practice staff. This is a burden for many GPs and when the anticipated increase in the frequency and length of rural placements occurs what is currently a burden will become unsustainable. The changing gender and cultural demographics of medical students and rural general practitioners will also contribute to stresses on this accommodation system. It is important to have a systematic approach towards more appropriate and sustainable models of accommodation for both medical students and GP registrars