Michael Kyrios¹, Barbara Jones¹, Kathryn I’Anson², Jane Gunn³ and Sunil Bhar4
¹ Swin-PsyCHE Research Unit, Swinburne University
² Anxiety Recovery Centre, Victoria
³ Department of General Practice, University of Melbourne
4 Department of Psychiatry, University of Pennsylvania
beyondblue Victorian Centre of Excellence
Project completion year
Obsessive Compulsive Disorder (OCD) occurs when people have ongoing unwanted/intrusive thoughts and fears that cause anxiety – often called obsessions. These obsessions make people feel they need to carry out certain rituals in order to feel less anxious and these are known as compulsions.
OCD is the fourth most common psychiatric disorder. It is the tenth leading cause of disability in the world, and is a significant health service concern with high degrees of co-morbidity with around 50% of people with OCD presenting with major depression.
The objective of our study was to ascertain what management was available for people with OCD within primary care, and to develop models of collaboration between general practitioners and psychologists in providing Cognitive Behavioral Therapy (CBT) for OCD.
Following an extensive literature review, existing and possible models of collaboration were presented to a reference group of stakeholders including GPs, psychologists, consumers and representatives from mental health services and community groups. Enablers and barriers to the various models were identified by the participants.
The reference group analysis was followed by more detailed investigations of specific groups. Focus groups with consumers and psychologists, and interviews with GPs were conducted. A questionnaire that measures knowledge about and attitudes to OCD was developed and administered to these groups.
Stakeholders generally agreed that:
- OCD was not being identified or recognised in primary care
- GPs were neither aware of the effectiveness nor were able to administer CBT for OCD
- even psychologists could not always demonstrate specialist skills in the treatment of OCD.
Focus group results supported these findings. The findings informed the development of two OCD screening items for use by GPs in primary care, as well as three models of collaboration between GPs and psychologists in the delivery of CBT for OCD in primary care.
Each model included a 12 week CBT treatment program specific to OCD developed by Kyrios, Hordern and colleagues (Kyrios et al., 2004, 2007).
Model 1 consisted of patient referral by their GP to a specialist psychology clinic. For Model 2, patients were referred to a trained psychologist co-located in the GP’s clinic. Model 3 was a “Shared Care” model whereby the GP was trained in the administration of CBT for OCD and was involved in providing treatment with a similarly trained psychologist.
A partnership was developed between the Melbourne Division of General Practice (MDGP) and the Swin-PsyCHE Research Unit at Swinburne University. The Swinburne University Psychology Clinic constituted the specialist clinic to which GPs could refer people.
GP education sessions were conducted on the assessment, conceptualisation and psychological treatment of OCD, and online resources were provided.
Referring GPs were given the option of using whichever model best suited their clinical needs. Almost all referrals (94%) used Model 1.
There were no referrals via the co-location model, and few GPs chose to be involved in shared care.
Half the referrals (50%) came from GPs who had been involved in the education sessions, although many GPs had learned about the OCD program through a newsletter from their local Division of General Practice, word-of-mouth, or directly from consumers. Half the people referred (50%) presented with primary OCD, although a large proportion (39%) did not present with OCD or presented with OCD as a secondary problem. Some referrals (10%) were not followed up by people or were not appropriate for the treatment program.
Intervention effected significant and clinically meaningful symptomatic amelioration in OCD, depression, and anxiety symptoms.
Implications for Policy and Practice
The magnitude of change seen in OCD patients was similar to that for cohorts in previous studies from a specialist psychology trainee clinic at the University of Melbourne (Kyrios et al., 2004), and was consistent with outcomes from OCD treatment centres around the world. Hopefully as a result of this and other projects, increased knowledge about OCD and capacity building within primary care will lead to improved outcomes.
The evaluation of the OCD program is now expanding to include systemic variables such as referral patterns, use of psychotropic medications, etc. We hope to offer the OCD treatment program through other Divisions of General Practice.
Following changes to the Medicare arrangements whereby patients can access rebates for services by registered and clinical psychologists, the OCD treatment program is being redesigned to account for the possibility of group sessions to augment the individual treatment. This option will be particularly useful for more severe, co-morbid, resistant or complex cases.
Hopefully as a result of this and other projects, increased knowledge about OCD and capacity building within primary care will lead to improved outcomes.
About the Researchers
Professor Michael Kyrios has been an academic clinical psychologist for 20 years, and has now developed a team of clinicians and researchers with similar interests within the Swinburne University PsyCHE Research Unit. Their collective work with other primary care researchers, clinical services, professional bodies, and consumer organisations has led to the development of a specific interest in capacity building within primary care so that consumers have easier access to effective evidence-based psychological treatments. With Dr. Barbara Jones heading the primary care initiative, the group is continuing to examine the possible impact of psychologists within this setting.
Kyrios, M., Hordern, C. & Bhar, S. (2004). The specificity of symptom amelioration and cognitive change in Obsessive-Compulsive Disorder following cognitive-behavior therapy. Paper presented to Congress of the European Association for Behavioural & Cognitive Therapies, Manchester, UK.
Kyrios, M. Hordern, C. Moulding, R. Nedeljkovic M. & Bhar, S. (2007). Cognitive, symptomatic and functional changes following cognitive-behavior therapy for Obsessive-Compulsive Disorder. Paper accepted for the World Congress of Behavioral and Cognitive Therapies, Barcelona, Spain.