Anxiety disorder is a major public health issue. Citing from the Australian Institute of Health and Welfare (AIHW, 2020), anxiety disorder accounts for approximately 14.4% of Australians’ general disease prevalence. The disorder affects close to 6.9% of adolescents aged 4-17 years and one in every seven children (Vu, Biswas, Khanam, & Rahman, 2018). However, despite its prevalence and associated complications, service admission and effective therapeutic interventions are major concerns. In this regard, health professionals should provide services that have an evidence base. Furthermore, most government-funded programs require that all mental healthcare providers working in Australian primary care settings deliver efficient, cost-effective short-term interventions. On this basis, it is important to review evidence-based therapeutic interventions, in line with Australian government mental health reforms that focus on digital approaches to increase cost-effective accessibility.
Anxiety disorder is described as a condition accompanied by persistent, extreme, and improbable worry about life situations. This uneasiness could be multifocal such as lack of finance, family issues, health complications, and thoughts about the future. It is challenging and difficult to manage and is often complemented by several psychophysiological health conditions (Roomruangwong et al., 2018). Therefore, excessive worry and thoughts are the central features of anxiety disorder, such as generalized anxiety disorder (GAD) (Roomruangwong et al., 2018). The condition often emerges first during the early childhood years. The onset of anxiety disorders is concomitant with a worse clinical progression over the individual’s lifespan. For instance, it is the most prevalent mental disorder in children and is responsible for most primitive psychopathology forms (Roomruangwong et al., 2018). If left unmanaged, anxiety may develop severe medical complications.
Case Scenario of Anxiety Disorder
Amelia is an 18-year-old woman from Maldon a rural town in Australia. She lives with her younger siblings (aged 8 and 12) after her parents’ death through depression. She visits a mental health provider regarding feeling stressed.
Past Medical History
Amelia has been attending a psychiatric health center at the Sydney Mental health facility for the past two years, often disturbed about her condition. She is in her final year of high school and has a history of GAD. Unfortunately, Amalia has been missing her antidepressant medications because of a lack of financial resources. When she was 16, she took an overdose in an attempt to commit suicide after her parents’ death.
Amelia affirms that since her parents’ death, she has had problems dealing with day-to-day life stressors. She fears for her siblings’ health and life situations. For instance, Amalia gets “in a state” and hope for the “the worst,” especially when her siblings get ill. Occasionally, her state of anxiety degenerates to a point she needs someone to comfort her. Her situation has recently deteriorated, and she has been taking alcohol to “calm down.”
Anxiety disorder has various treatment interventions that include psychoeducational programs, pharmacological, and cognitive-behavioral therapy (CBT). Psychoeducational programs provide education to the patient concerning the anxiety, its manifestation, causes, and implications (Saito-Tanji, Tsujimoto, Taketani Yamamoto, & Ono, 2016). Pharmacological interventions involve the use of drugs such as antidepressants to manage anxiety. For example, venlafaxine, a serotonin and noradrenaline reuptake inhibitor (SNRI) is used to treat mental illness such as anxiety. CBT is a type of psychological management used in the treatment and control of anxiety. It is a focused, therapeutic approach based on the foundation that cognitions affect sensations and behaviors (Te Brinke, Schuiringa, Menting, Deković, & De Castro, 2018). In Australia, digital-based CBT is provided in psychiatric healthcare settings.
CBT is available as internet-based (iCBT) program. iCBT engages patients in structured mental healthcare programs whose content is similar to and based on the therapist’s CBT programs. iCBT programs vary in styles, degree of complexity, content, and the level of involvement by psychiatrists (Newby, Mewton, & Andrews, 2017). Treatment programs have been studied in patients with mild-to-moderate or severe anxiety disorders with worrying concerns over the quality of the research programs. However, with advancements in technology, internet intervention has provided therapeutic managements to individuals with low access to effective treatments.
Several other barriers affect the management of anxiety. For example, other barriers to effective access to anxiety interventions include low household income, poor academic achievements, and lack of parental care (Vu et al., 2018). Living with younger siblings and the level of education are established enablers to development of anxiety (Kuringe et al., 2019). In this case, Amalia, who is living with her siblings without parents, is at risk of developing complicated forms of anxiety. According to Lebowitz, Leckman, Silverman, and Feldman (2016), genetic factors of the first-degree relatives with anxiety conditions may transfer their “bad genes” to their immediate children. In essence, Amalia’s anxiety may be because of predisposing genetic factors, noting that her parents died from depression. Moreover, slow or unreliable internet access may limit some of the iCBT programs to patients suffering from anxiety disorders.
Several scientific researches have explored the utilization of internet-based therapeutic interventions in addressing the accessibility of cost-effective psychological management of anxiety. Cromarty, Drummond, Francis, Watson, and Battersby (2016) adopted NewAccess services that use the “stepped care” model to study the program’s effectiveness in addressing anxiety in Australia. NewAccess program replicates the UK Improving Access to Psychological Therapies (IAPT) that used CBT and achieved a 55-56% recovery rate (Cromarty et al., 2016). NewAccess program is a low-intensity CBT (LiCBT) which provides face-to-face and internet-based intervention by qualified practitioners. Cromarty et al. (2016) case study consisted of 892 patients diagnosed with moderate or worse anxiety, and 1107 patients detected with either moderate or worse anxiety. The “coaches” comprised of well-trained individuals with the ability to perform NewAccess programs.
Participants were placed under a six-session program composed of face-to-face, internet-based coaching during the program. Anxiety was measured in each session using the Generalized Anxiety Disorder Questionnaire 7 (GAD-7) with anxiety scores of range (0-21), 21 indicating higher anxiety, 10 or less mild anxiety, and 5 or less asymptomatic. The procedure was done before therapy and at the discharge of the program after testing asymptomatic. The results indicated a reduction in GAD-7 scores from the program’s onset to discharge, t (1408) =44.43, p<.001, Cohen’s d=1.15 (Cromarty et al., 2016). Based on the GAD-7 scores, 73.6% of the 892 patients with moderate to worse anxiety during admission indicated mild or improved anxiety scores at discharge (Cromarty et al., 2016). NewAccess indicates improved GAD-7 scores to patients with anxiety. For instance, in Cromarty et al. (2016) study, 69.29% showed mild or improved GAD-7 scores at discharge from the 1107 patients with moderate or worse anxiety or both. Therefore, this recovery rate implies that the NewAccess program adopted in Australia, successfully addresses anxiety and anxiety-related disorders.
MindStep is an evidence-based treatment control designated for the management of mental health disorders such as anxiety. In Australia, it adopts the approaches made in the UK IAPT and is delivered through a comprehensive telephone-based intervention, targeting patients with a recent history of mental health admission within the private sector. Lawn et al. (2019) conducted a study to comprehend the outcome of mobile-delivered LiCBT to people living within a community with recent hospital admission because of anxiety. The study employed a qualitative methodology to compare pre- and post-treatment clinical outcomes based on a cohort of (N=680) clinical subjects with anxiety disorders. Lawn et al. (2019) utilized a Patient Health Questionnaire (PHQ-9) and GAD-7 to determine the subjects’ anxiety. The anxiety scores were then used to determine individual’s recovery rate.
MindStep provides high anxiety recovery rates. For instance, MindStep indicated a recovery rate of 62% (95% Cl: 57-68%) after a ‘per-protocol’ analysis involving (N=427) with post-treatment PHQ-9 OF (d=1.03) and GAD-7 (d=0.99) (Lawn et al., 2019). However, for intent-to-treat analysis with multiple imputation analysis (N=680) of clients who commenced the treatment but never completed, a 49% reliable recovery rate was established (95% Cl: 45-54%) (Lawn et al., 2019). MindStep also demonstrates encouraging outcomes that suggest LiCBT provides successful anxiety treatment to patients with a history of successive hospital admissions, with a recovery rate of more than 50% (Lawn et al., 2019). Therefore, MindStep is easily accessible, feasible, and safe within the “stepped modes” of mental healthcare provision in Australia.
In order to provide cost-effective, feasible, and accessible anxiety management to patients, it is important to analyze the available evidence-based therapeutic interventions. This should follow stipulated guidelines by the Australian government mental health reforms that focus on digital approaches. Understanding the barriers and enablers to accessing these interventions provides a comprehensive approach to psychological interventions that minimize cost and maximize benefits. Several therapeutic controls related to the mediation of anxiety and anxiety disorders have been discussed. For instance, psychoeducational programs, the use of pharmacological interventions, and CBT are the common pharmacological and non-pharmacological forms of managing anxiety. However, NewAccess programs and MindStep, which deliver improved recovery rates compared to the UK IAPT has been adopted. Therefore, both policies provide promising outlook since they are accessible, cost-effective, and safe within the Australian mental health delivery systems.
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