Norms for Zung's Self-rating Anxiety Scale

BackgroundZung's Self-rating Anxiety Scale (SAS) is a norm-referenced scale which enjoys widespread use a screener for anxiety disorders. However, recent research (Dunstan DA and Scott N, Depress Res Treat 2018:9250972, 2018) has questioned whether the existing cut-off for identifying the presence of a disorder might be lower than ideal.MethodThe current study explored this issue by examining sensitivity and specificity figures against diagnoses made on the basis of the Patient Health Questionnaire (PHQ) in clinical and community samples. The community sample consisted of 210 participants recruited to be representative of the Australian adult population. The clinical sample consisted of a further 141 adults receiving treatment from a mental health professional for some form of anxiety disorder.ResultsMathematical formulas, including Youden's Index and the Receiver Operating Characteristics Curve, applied to positive PHQ diagnoses (presence of a disorder) from the clinical sample and negative PHQ diagnoses (absence of a disorder) from the community sample suggested that the ideal cut-off point lies between the current and original points recommended by Zung.ConclusionsConsideration of prevalence rates and of the potential costs of false negative and false positive diagnoses, suggests that, while the current cut-off of 36 might be appropriate in the context of clinical screening, the original raw score cut-off of 40 would be most appropriate when the SAS is used in research

Clarification of the cut-off score for Zung's self-rating depression scale

Background: Zung’s Self-rating Depression Scale (SDS) is an established norm-referenced screening measure used to identify the presence of depressive disorders in adults. Despite widespread usage, issues exist concerning the recommended cut-off score for a positive diagnosis. First, confusion arising from the conversion of raw scores to index scores had resulted in a considerably higher cut-off score than that recommended being used by many researchers. Second, research in China [Chin J Nervous Mental Dis. 12:267-268; 2009] and Australia [BMC Psychiatry. 17:329; 2017] had suggested that the current recommended cut-off is lower than ideal, at least in those countries. Method:To explore these matters further, sensitivity and specificity figures for alternative cut-off points were examined in positive clinical and negative community samples respectively. The positive clinical sample (n = 57) consisted of adults receiving treatment from a medical professional for some kind of depressive disorder, whose diagnosis was positively confirmed using the Patient Health Questionnaire (PHQ). The negative community sample (n = 172) was derived from a representative sample of adults whose absence of any depressive disorder was similarly confirmed by the PHQ. Results: Mathematical models, including Youden’s Index and the Receiver Operating Characteristics Curve, suggest that the recommended cut-off (a raw score of 40) is indeed too low. More detailed comparisons, including consideration of the likely numbers of false positives and negatives given prevalence rates, confirm that, ironically, the incorrect SDS cut-off score mistakenly applied by many researchers (a raw score of 50) would appear to provide far greater accuracy. Conclusions: Research in China [Chin J Nervous Mental Dis. 12:267-268; 2009] has resulted in an elevated SDS cut-off score of 42 being used in many Chinese studies. Research by Dunstan and Scott [BMC Psychiatry. 17:329; 2017] in an Australian context, suggested that a greater increase, to a raw score of 44 might be required. Based on this study, an even larger adjustment is required. Specifically, we recommend the use of an SDS raw score of 50 as the cut-off point for clinical significance

Assigning Clinical Significance and Symptom Severity Using the Zung Scales: Levels of Misclassification Arising from Confusion between Index and Raw Scores

Background. The Zung Self-Rating Depression Scale (SDS) and Self-Rating Anxiety Scale (SAS) are two norm-referenced scales commonly used to identify the presence of depression and anxiety in clinical research. Unfortunately, several researchers have mistakenly applied index score criteria to raw scores when assigning clinical significance and symptom severity ratings. This study examined the extent of this problem. Method. 102 papers published over the six-year period from 2010 to 2015 were used to establish two convenience samples of 60 usages of each Zung scale. Results. In those papers where cut-off scores were used (i.e., 45/60 for SDS and 40/60 for SAS), up to 51% of SDS and 45% of SAS papers involved the incorrect application of index score criteria to raw scores. Inconsistencies were also noted in the severity ranges and cut-off scores used. Conclusions. A large percentage of publications involving the Zung SDS and SAS scales are using incorrect criteria for the classification of clinically significant symptoms of depression and anxiety. The most common error—applying index score criteria to raw scores—produces a substantial elevation of the cut-off points for significance. Given the continuing usage of these scales, it is important that these inconsistencies be highlighted and resolved

Evidence-Based Practice by Psychologists Treating Secondary Psychological Injuries Within State Insurance Regulatory Authority Governed Frameworks

While psychopathology arising from musculoskeletal injury (i.e., secondary psychological injury) is predictive of poor recovery by injured people claiming compensation, the application of evidence-based practice (EBP) treatment guidelines is associated with improved outcomes. In 2010, the State Insurance Regulatory Authority (SIRA) in New South Wales (NSW), Australia- a body that governs the regulatory functions of Workers Compensation (WC) and motor vehicle Compulsory Third Party (CTP) insurance schemes-implemented EBP treatment guidelines. These guidelines are contained in the document titled: Clinical framework for the delivery of health services (Transport Commission & WorkSafe Victoria, 2012). At the time of conducting this research, the SIRA EBP treatment guidelines had been in effect for over five years; however, their effect on psychologists' practice and injured persons' outcomes was unknown. Therefore, the aims of the thesis were to: 1) to examine the effect of the introduction of the EBP treatment guidelines on claims cost and injured person outcomes within the SIRA insurance schemes and assess the use of EBP by psychologists treating musculoskeletal injuries with secondary psychological injury in this context, 2) to identify barriers to psychologists' use of EBP from the perspective of psychologists and 3) from the perspective of key stakeholders and 4) to elicit and test the feasibility of recommendations made by expert psychologists to improve psychologists' practice. Study 1 investigated whether the implementation of EBP treatment guidelines had reduced claims costs, improved injured person outcomes and resulted in psychologists using EBP. From a time range sample of n = 238 administrative records of people with a musculoskeletal injury and secondary psychological injury, the results revealed that the implementation of EBP had acted as a buffer against broader negative trends in claims cost and return to work timeframes (i.e., compared to the population of injured people n = 26,254 who had suffered a musculoskeletal injury and not consulted a psychologist during the same time period). The second phase of the study included a qualitative case-level analysis of n = 12 WC files and n = 9 CTP showed that within both WC and CTP positive injured person outcomes occurred when psychologists' adherence with EBP guidelines was high. However, the findings also showed that psychologists' application of EBP treatment guidelines was suboptimal. Study 2 explored the barriers in psychologists' adherence with the SIRA EBP guidelines. Psychologists (n = 20) practicing within rural, regional and metropolitan in NSW participated in focus groups. The results revealed three key issues functioned as barriers: 1) a lack of trust in the validity of the recommended EBP guidelines, 2) a lack of knowledge of the psychologist's role in this context and insufficient skills to fully apply the guidelines, protocols and procedures and 3) a poor fit between EBP guidelines, client presentations and circumstances and the SIRA compensation schemes. The findings showed that both individual practitioner variables and contextual barriers influenced adherence to EBP. Study 3 explored the contextual barriers that were identified in Study 2 as affecting practice. These included perceived barriers created by general practitioners (GPs), insurers and injured patients' actions. A sample of n = 27 participants was involved. The results showed that GPs were reticent to access psychological services due to a poor fit between their practice and treatment guidelines. Insurers lacked trust in the validity of 'secondary psychological injury' claims and this was exacerbated by psychologists' non-adherence to insurers' protocols and deficits in insurers' knowledge. Injured peoples' willingness to engage with treatment was impaired by a poor fit between the treatment guidelines and their experience of insurers' and psychologists' practices. Study 4 elicited recommendations to overcome the barriers in psychologists' adherence to EBP guidelines that were identified in Study 2 and examined the feasibility of their implementation. The recommendations proposed by field experts (n = 8) included: 1) mandatory training and continuing professional development in the area of practice, 2) using independent consultants for expert advice, 3) completion of outcome measures prior to the first session, 4) completion of a treatment plan in-session with the injured person and 5) completion of outcome measures in the eighth and final session. These recommendations were considered feasible by most of the participating psychologists (n =150). Taken together, the findings of this project highlight the important role of psychologists in the treatment of musculoskeletal injuries with secondary psychological injury and reinforced the need to integrate the best available research evidence with clinician's expertise and patient expectations and values to deliver beneficial outcomes to people. In addition, the findings illustrate that while psychologists have skills in the treatment of mental disorders they may not be competent in EBP approaches for managing and addressing pain and functional disability arising from secondary psychological injury within the compensation frameworks. The findings also highlight that to increase the application of EBP guidelines, a broad-based commitment from all stakeholders within the SIRA compensation schemes is required. This includes education programs that support all stakeholders to understand that the management of secondary psychological injuries requires a functional restoration perspective within a biopsychosocial paradigm. Lastly, empirical data from the research can be used to encourage stakeholders to change their practices and for policymakers, administrators and professional associations to provide support to facilitate psychologists' adherence with EBP in ordinary clinical settings

What Social Supports Are Available to Self-Employed People When Ill or Injured? A Comparative Policy Analysis of Canada and Australia

Self-employment (SE) is a growing precarious work arrangement internationally. In the current digital age, SE appears in configurations and contours that differ from the labor market of 50 years ago and is part of a 'paradigm shift' from manufacturing/managerial capitalism to entrepreneurial capitalism. Our purpose in this paper is to reflect on how a growing working population of self-employed people accesses social support systems when they are not working due to injury and sickness in the two comparable countries of Canada and Australia. We adopted 'interpretive policy analysis' as a methodological framework and searched a wide range of documents related to work disability policy and practice, including official data, legal and policy texts from both countries, and five prominent academic databases. Three major themes emerged from the policy review and analysis: (i) defining self-employment: contested views; (ii) the relationship between misclassification of SE and social security systems; (iii) existing social security systems for workers and self-employed workers: Ontario and NSW. Our comparative discussion leads us toward conclusions about what might need to be done to better protect self-employed workers in terms of reforming the existing social security systems for the countries. Because of similarities and differences in support available for SE'd workers in the two countries, our study provides insights into what might be required to move the different countries toward sustainable labour markets for their respective self-employed populations

Can a Smartphone App Make you Feel Super Better? A Pilot Study Utilizing a Multiple Single-Case Design

This dataset contains the de-identified data of four individuals who participated in this pilot study using the mental health app, SuperBetter. A multiple single-case design was used. The dataset contains: 1. Daily distress ratings, known as Subjective Units of Distress (SUDS); 2. Anxiety and depression symptom outcome ratings, captured at four different time points by the Depression Anxiety Stress Scale - 21 Item Version (DASS-21); 3. Life functioning ratings captured at four different time points by the Outcome Questionnaire - 45 Item Version 2nd Edition (OQ-45.2); 4. Demographic information captured by our demographics questionnaire; and 5. Final app rating and appraisal captured by the Mobile Application Rating Scale - User Version (uMARS). The dataset contains both raw data files and graph / figure files for visual analysis. For more information on the background, method, results and discussion of this dataset, see the published research protocol article that covers both this pilot study and main intervention study (Marshall, Dunstan, & Bartik; 2020), and published pilot study article

Treating Psychological Trauma in the Midst of COVID-19: The Role of Smartphone Apps

With the COVID-19 pandemic confronting health systems worldwide, medical practitioners are treating a myriad of physical symptoms that have, sadly, killed many thousands of people. There are signs that the public is also experiencing psychological trauma as they attempt to navigate their way through the COVID-19 restrictions impinging on many aspects of society. With unprecedented demand for health professionals' time, people who are unable to access face-to-face assistance are turning to smartphone apps to help them deal with symptoms of trauma. However, the evidence for smartphone apps to treat trauma is limited, and clinicians need to be aware of the limitations and unresolved issues involved in using mental health apps

Apps With Maps - Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores

Background: Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy.Objective: This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area.Methods: A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach.Results: Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy.Conclusions: The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps

Effectiveness of Using Mental Health Mobile Apps as Digital Antidepressants for Reducing Anxiety and Depression: Protocol for a Multiple Baseline Across-Individuals Design

Background: The use of mental health mobile apps to treat anxiety and depression is widespread and growing. Several reviews have found that most of these apps do not have published evidence for their effectiveness, and existing research has primarily been undertaken by individuals and institutions that have an association with the app being tested. Another reason for the lack of research is that the execution of the traditional randomized controlled trial is time prohibitive in this profit-driven industry. Consequently, there have been calls for different methodologies to be considered. One such methodology is the single-case design, of which, to the best of our knowledge, no peer-reviewed published example with mental health apps for anxiety and/or depression could be located.Objective: The aim of this study is to examine the effectiveness of 5 apps (Destressify, MoodMission, Smiling Mind, MindShift, and SuperBetter) in reducing symptoms of anxiety and/or depression. These apps were selected because they are publicly available, free to download, and have published evidence of efficacy.Methods: A multiple baseline across-individuals design will be employed. A total of 50 participants will be recruited (10 for each app) who will provide baseline data for 20 days. The sequential introduction of an intervention phase will commence once baseline readings have indicated stability in the measures of participants’ mental health and will proceed for 10 weeks. Postintervention measurements will continue for a further 20 days. Participants will be required to provide daily subjective units of distress (SUDS) ratings via SMS text messages and will complete other measures at 5 different time points, including at 6-month follow-up. SUDS data will be examined via a time series analysis across the experimental phases. Individual analyses of outcome measures will be conducted to detect clinically significant changes in symptoms using the statistical approach proposed by Jacobson and Truax. Participants will rate their app on several domains at the end of the intervention.Results: Participant recruitment commenced in January 2020. The postintervention phase will be completed by June 2020. Data analysis will commence after this. A write-up for publication is expected to be completed after the follow-up phase is finalized in January 2021.Conclusions: If the apps prove to be effective as hypothesized, this will provide collateral evidence of their efficacy. It could also provide the benefits of (1) improved access to mental health services for people in rural areas, lower socioeconomic groups, and children and adolescents and (2) improved capacity to enhance face-to-face therapy through digital homework tasks that can be shared instantly with a therapist. It is also anticipated that this methodology could be used for other mental health apps to bolster the independent evidence base for this mode of treatment.International Registered Report Identifier (IRRID): PRR1-10.2196/1715