random but important npe

National Health and Medical Research Council (NHMRC) has developed an evidence hierarchy which serves as a framework to categorise and assess the strength of evidence derived from different types of research studies

Level I

A meta-analysis or a systematic review of level II studies that included a quantitative analysis

Level II

A randomised controlled trial. A study of test accuracy with: an independent, blinded comparison with a valid reference standard, among consecutive persons with a defined clinical presentation

Level III-1

A pseudorandomised controlled trial (i.e. alternate allocation or some other method)

Level III-2

A comparative study with concurrent controls: -

Non-randomised, experimental trial

Cohort study -

Case-control study -

Interrupted time series with a control group

Level III-3

A comparative study without concurrent controls:

Historical control study

Two or more single arm study

Interrupted time series without a parallel control group

Level IV

Case series with either post-test or pre-test/post-test outcomes

randomised controlled trials

• have long been considered the gold standard for evaluating the effectiveness of interventions, the limitations of this research design are acknowledged in the current review.

• There may, for example, be aspects of an individual’s presentation or the treatment conditions that make it impossible to undertake randomisation or to eliminate bias even with the adoption of the most rigorous research methodology.

• The findings from RCTs may therefore be limited in reflecting the external validity of real-life settings, diversity of client populations, and specific cultural considerations.

• More recent discussion is focussing on the value of lived experience perspectives to contribute to research and practice.

• It is important to note that evidence used in this review is available only where the associated research has been undertaken and published, and some interventions and/or diagnoses may be more widely researched or more easily lend themselves to RCTs (e.g., those based on manualised treatment protocols). The absence of evidence does not therefore necessarily equate to an intervention being ineffective.

• Much has been written about the importance of the therapeutic relationship, clinician training and experience, and client attitudes, preferences, and adherence to treatment.

• In particular, extensive research has acknowledged the important relationship between therapeutic alliance and treatment outcomes.

• Health professionals must use their professional judgement in determining the most appropriate intervention approach based on the current evidence base and consideration for the client's individual circumstances and contextual factors.

interventions for depression

Level I evidence has been found in support of the following interventions for the treatment of depression

in adults:

- Acceptance and commitment therapy

- Cognitive behaviour therapy

- Eye movement desensitisation and reprocessing

- Interpersonal psychotherapy

- Mindfulness-based cognitive therapy

- Problem-solving therapy

- Short-term psychodynamic therapy

- Psychoeducation

- Self-guided digital interventions

Level II evidence has been identified in support of dialectical behaviour therapy, emotion-focused therapy, family-based interventions, schema therapy, and solution-focused therapy

interventions for bipolar disorder

Level I evidence54 has been identified in support of individual cognitive behaviour therapy in the treatment of bipolar disorder in adults. Level II evidence was found in support of group acceptance and commitment therapy, family-based interventions, and interpersonal and social rhythm therapy (retained from 2018 edition). Level II evidence was also found for dialectical behaviour therapy, however study results only indicated efficacy for symptoms of mania but not depression

Level I evidence in relation to self-guided digital interventions found mixed evidence, where the higher quality study did not find support for smartphone-based interventions. Level I evidence in relation to group cognitive behaviour therapy did not indicate efficacy for the treatment of depression or mania. Level II evidence in relation to mindfulness-based cognitive therapy also did not provide support for its efficacy when compared to a passive control group. Level I evidence in relation to group psychoeducation indicated some efficacy, however this effect was only found in the case of relapse prevention and not for the reduction of depression or manic symptoms

interventions for GAD

This review identified Level I evidence in support of cognitive behaviour therapy, interpersonal psychotherapy, and self-guided digital interventions in the treatment of generalised anxiety disorder (GAD) in adults. Self-guided digital interventions included internet-based cognitive behaviour therapy and psychodynamic therapy, with none-to-minimal therapist guidance. Level II evidence was found to support the use of acceptance and commitment therapy (individual and group), mindfulness-based stress reduction, mindfulness-based cognitive therapy, psychodynamic therapy, and psychoeducation (group).

Guidelines provided by WHO (2023) and RANZCP (2018) provide recommendations in support of the use of cognitive behaviour therapy, self-guided digital interventions (specifically internet-based CBT) and psychoeducation in the treatment of GAD in adults.

interventions for SAD

Level I evidence was found in support of cognitive behaviour therapy, self-guided digital interventions (including internet-delivered and application-delivered CBT), interpersonal psychotherapy, and psychodynamic therapy in the treatment of social anxiety disorder in adults. Level II evidence was identified in support of acceptance and commitment therapy, compassionfocused therapy, and mindfulness-based stress reduction adapted for social anxiety disorder. Statements made on the efficacy and/or level of support identified for an intervention are based on the article identified as having 1) highest level of evidence based on NHMRC levels of evidence hierarchy, 2) the lowest risk of bias as assessed using the appropriate Cochrane Risk of Bias tool, and 3) the most recent publication date, in that order. Accordingly, the articles presented below may not be reflective of the whole body of current evidence on the efficacy of any given intervention in the treatment of social anxiety disorder in adults. Guidelines provided by RANZCP (2018) and NICE (2013) endorse the use of cognitive behaviour therapy in both face-to-face and digital formats as a first-line treatment for social anxiety disorder in adults.

interventions for specific phobia

Level I evidence was identified in support of cognitive behaviour therapy (specifically, exposure therapy) and eye movement desensitisation and reprocessing in the treatment of specific phobia in adults. It was noted that the evidence for exposure therapy published after 2018 was primarily focused on virtual reality exposure therapy. In addition to this, Level II evidence was identified for the use of self-guided digital interventions in the provision of exposure therapy.

interventions for PTSD

cognitive therapy for PTSD, cognitive processing therapy, prolonged exposure, narrative exposure therapy, as well as manualised trauma-focused cognitive behaviour therapy (TF-CBT) under the same umbrella. (Upon expert review, imagery rescripting was added to the intervention list for this chapter.)

Level I evidence has been identified in support of cognitive behaviour therapies with a trauma focus, with narrative exposure therapy being effective for adult refugee populations. Level I evidence was additionally found supporting individual cognitive behaviour therapy without a trauma focus, eye movement desensitisation and reprocessing, imagery rescripting, and mindfulness-based stress reduction. Evidence supporting self-guided interventions was also found. Specifically, internet-based cognitive behaviour therapy was supported with Level I evidence, whilst internetbased stress management approaches were supported with Level II evidence. Level II evidence was found in support of dialectical behavioural therapy, emotion-focused therapy, and mindfulness-based cognitive therapy.

Level II evidence was found in support of interpersonal psychotherapy, although it was not found to be superior to the active control. Level I evidence in relation to hypnotherapy was identified, however findings on the efficacy were mixed. Guidelines provided by Phoenix Australia (2023), WHO (2023), the U.S. Department of Veteran Affairs Management of Posttraumatic Stress Disorder Work Group (2023), and ISTSS (2020) provide recommendations in support of trauma-focused cognitive behaviour therapy, cognitive processing therapy, eye movement desensitisation and reprocessing, and prolonged exposure therapy.60 Additionally, some interventions that were outside the scope of the review but were conditionally recommended by these guidelines include narrative exposure therapy, present-centred psychotherapy, and stress inoculation training