Full details of the post-hoc analyses by Professor Mark Anderson and Dr. Clive Jones (2017)

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United Profession – Equality of Practitioner – Freedom of Treatment

Mental Health Treatment in Australia Today

Outcomes in Psychology Practice Under Medicare Better Access

Compiled by: Dr Clive Jones Dipt, DipCouns, DipLC, BEd, MEd, GradDipPsych, PhD(psych), MAPS, MCCOUNP, MCSEP.

17th January 2017

INTRODUCTION

Since the introduction of Medicare Better Access to Mental Health Care in November of 2006 a misconception has become imbedded within Australia’s National Mental Health Care System that incorrectly infers clinical psychologists hold a greater level of expertise and quality of service in the treatment of mental health compared to all other psychologists practicing in the same field.

The unfortunate ramifications of this misconception are inequities for most psychologists currently practicing in the field of mental health and include a disparity in remuneration, restrictions in scope of practice and shifts in both public and professional perceptions of expertise.  The ramifications of these three disparities are quite profound.

This brief report offers clarity on research that speaks to these misconceptions.

 

RESEARCH FINDINGS 

In 2009 & 2010 the Australian Government through the Department of Health & Ageing funded research to obtain clarity on the benefits of the Medicare Better Access to Mental Health Initiative. The scope of this research commissioned by the Australian Government focused very specifically on determining the treatment outcomes of three specific groups treating under the Medicare Better Access Initiative. These three groups were: 1) the tier one clinical psychologist group, 2) the tier two generalist psychologist group and 3) the GP focused psychological strategies group.

The findings of this research were published in 2011[1] and additional post-hoc analysis[2] of the 2011 data was conducted in 2016 to offer further clarity on the original findings established in 2011.

The table on the following page is an extract from this 2011 publication1 (p. 734) and offers a comprehensive overview of the following:

  • Pre/post measures and mean group differences derived from the K-10 and the three (3) subscales of the DASS (i.e., Depression, Anxiety & Stress)
  • Comparisons across clinical, generalist and GP treatment groups, and
  • Comparisons between mild, moderate and severe pre-treatment client groups.

The 2011 research examined pre/post treatment measures using the K-10 and the three (3) subscales of the DASS (i.e. Depression, Anxiety & Stress). Results of the research showed a clear reduction in symptoms post treatment across all measures of the K-10 and DASS and across both groups of psychologists (i.e., both generalists and clinical).

It was noted in the pre/post scores of symptom reduction the ‘clinical’ and ‘generalist’ psychologist groups were equivalent in treatment outcomes across mild, moderate and severe cases while the GP group had a lower symptom reduction post treatment across all cases.

Ultimately the findings of this research showed that:

  • all groups (i.e., clinical psychologists, generalist psychologists and GP’s) showed symptom reduction (as measured by the K-10 & DASS) post treatment
  • The psychologist group combined (i.e., clinical and generalist) showed greater symptom reduction post treatment compared to the GP group
  • There was no difference in post treatment measures between the clinical psychology group and the generalist psychology group.

 

Conclusion derived from this research: There is no difference in treatment outcome between the clinical psychology group and the other registered psychology group.

POST-HOC ANALYSIS OF FINDINGS

Post Hoc analysis (i.e., additional analysis after the study is complete) of the data from the 2011 Government Commissioned study was conducted by Prof Mark Anderson[3] in December 2016 to provide further clarity on outcome differences between the clinical psychology group and registered psychology group treating under Medicare Better Access.

The post hoc analysis applied by Prof Anderson was the ‘Cohens d’ which is used to directly compare the effect size difference pre/post treatment. The Cohens d rating of effect size is outlined below.

  • Small effect size between pre/post treatment: d=0.20
  • Medium effect size between pre/post treatment: d=0.50
  • Large effect size between pre/post treatment: d=0.80
  • Very large effect size between pre/post treatment: d=1.20

Professor Mark Anderson explains (email correspondence: 15th December 2016):

“the main article did not go far enough in its analysis of differences (or no differences) between groups, but with the stats supplied in the article I was able to calculate the repeated-measures effect sizes (Cohen’s d) for the pre/post measures for the reduction in scores for K-10 and the three DASS subscales for clinical and general psychologists. That calculation is done by taking the mean difference values (column in the Table 5 on page 734 labeled “Mean difference (SD)”) and dividing them by the SD of the difference scores (also supplied in that column). All the Cohen’s d values are, by the conventional standards of psychological research, in the large (d=.80) to very large (d=1.20)” range.”

 

Conclusion derived from post-hoc analysis of original research:

It can be concluded from the table on the previous page that all effect size results across the clinical and general registered group in the post hoc analysis are either large or very large with Cohen’s d ranging between 0.82 through to 1.20 demonstrating the power of the results and the significance of the findings.

It is also clear from the findings that there is no difference between Tier One Clinical Psychologists and Tier Two Generalist Psychologists in outcomes as measured by the K-10 and DASS pre/post treatment.

Professor Mark Anderson offers three (3) key points to conclude on the findings of the post hoc analysis (Email correspondence: 15th December 2016):

  1. “Effect sizes are much more meaningful and interpretable that p values and tests of statistical significance. The Ns (sample population) here are quite large, so one can be fairly confident in the reliability of the resulting effect sizes.”
  1. “What one can see quite clearly is that the changes in scores on these four measures do not differ in any meaningful way between clinical and general psychologists.”
  1. “We don’t need any further statistical test to come to the conclusion that there are no meaningful differences in outcomes on these measures between clinical and general psychologists.”

 

CONCLUSION

There is no difference in outcomes as measured by the K-10 and DASS pre/post treatment when comparing the tier one clinical psychology group and tier two other registered psychology group treating under Medicare.

Ultimately, we do not require any further evidence to conclude that there are no meaningful differences in outcomes on these measures between clinical and general psychologists whereby we must accept that all psychologists across both tiers of Medicare are equally effective in treating mental health concerns.

The implications of these findings are huge in that they confirm the current inequities faced by most psychologists practising in the field of mental health are unwarranted and highly inappropriate.

To safeguard optimal care of patients it is imperative that policy on mental health is properly informed to ensure systems are founded on the science of best practice. It is unfortunate that the Better Access to Mental Health Care Initiative was established with a fundamental flaw in the unfounded premise of difference in expertise between one group of psychologists over another.

It is time for the APS to speak clearly on the science as it presents and advocate for a single tier under Medicare Better Access to Psychologists.

 

[1] Pirkis, J., Ftanou, M., Williamson, M., Machlin, A., Spittal, M. J., Bassilios, B., & Harris, M. (2011). Australia’s better access initiative: An evaluation, 45, 726-739. The Royal Australian and New Zealand College of Psychiatrists.

[2] Professor of Psychology Mark Anderson Halmstad University, Sweden, (2016). Post Hoc Analysis of research on Australia’s better access initiative

[3] Professor of Psychology Mark Anderson Halmstad University, Sweden, (2016). Post Hoc Analysis of research on Australia’s better access initiative

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