The involvement of paraprofessionals for anxiety and depressive disorders

The established mental health care system does not have the resources to meet the increasing need for care of those with anxiety and depressive disorders. This review investigated the effectiveness of any kind of psychological treatment conducted by paraprofessionals.The few studies found did not allow conclusions about the effect of paraprofessionals compared to professionals in the treatment of anxiety and depressive disorders. Pooling data from three studies, involving women only, indicated a significant effect for paraprofessionals compared to no treatment. The evidence so far may justify the development and evaluation of programs incorporating paraprofessionals in treatment programs for anxiety and depressive disorders.

Authors' conclusions: 

The few studies included in the review did not allow conclusions about the effect of paraprofessionals compared to professionals, but three studies (women only) indicated a significant effect for paraprofessionals (all volunteers) compared to no treatment. The evidence to date may justify the development and evaluation of programs incorporating paraprofessionals in treatment programs for anxiety and depressive disorders.

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Background: 

The established mental health care system does not have the resources to meet the extensive need for care of those with anxiety and depressive disorders. Paraprofessionals partially replacing professionals may be cost-effective.

Objectives: 

To investigate the effectiveness of any kind of psychological treatment for anxiety and depressive disorders performed by paraprofessionals. To examine whether the results apply to clinically significant disorders.

Search strategy: 

CCDANCTR-Studies, EMBASE (ExerptaMedica), MEDLINE, PsycINFO, all years published using the key words: para-/paraprofessional, non-/nonprofessional, rand*, psy*; peer; volunt*; citation lists of articles reviewing the subject and included studies; correspondence with authors of controlled studies, and review reports on the subject.

Selection criteria: 

Randomised controlled trials that used symptom measures, and compared the effects of treatments given by paraprofessionals (paid or voluntary, unqualified with respect to the psychological treatment) with treatments given by professionals, and with waiting list or placebo condition.

Data collection and analysis: 

The standard mean difference was used to pool continuous data, and odds ratios were used to pool dichotomous data, using a random effects model. The generic inverse variance method was used for combining continuous and dichotomous data. The effect of low quality studies and the use of self-rated versus observer-rated measures were tested. Subgroup analyses were performed for differences between depression and anxiety diagnosis, paraprofessionals with/without professional background, group/individual intervention, length of follow-up and gender (post-hoc subgroup analysis).

Main results: 

Five studies reported five comparisons of paraprofessionals versus professionals (n=106) and five comparisons of paraprofessionals versus control condition (n=220). No differences were found between paraprofessionals and professionals (SMD=0.09, 95% CI -0.23 to 0.40, p=0.58), and no significant heterogeneity. Studies comparing paraprofessionals versus control (mixed continuous and dichotomous data) showed a significant effect in favour of paraprofessionals (OR=0.34, 95% CI 0.13 to 0.88, p=0.03), but heterogeneity was indicated (I²=60.9%, Chi²= 10.24, df=4, p=0.04). After correction for heterogeneity and removing one study of low quality, the pooling of data from three studies (n=128; mixed gender; women) indicated no significant difference in effect between paraprofessionals and professionals (SMD=0.13, 95% CI -0.39 to 0.64; p=0.63) and a strongly significant pooled effect for three studies (n=188; women) favouring paraprofessionals over the control condition (OR=0.30, 95% CI 0.18 to 0.48, p<0.00001), and homogeneity indicated between studies (I²=0%, Chi²=0.47, df=2, p=0.79).

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