Long-term outcomes for the Child STEPs randomized effectiveness trial: a comparison of modular and standard treatment designs with usual care

Modular CBT for Childhood Anxiety Disorders: Evaluating Clinical Outcomes and its Predictors

This study examined clinical outcomes of a modular individual CBT for children with anxiety disorders (AD), and predictors of outcomes, in usual clinical practice. Participants were 106 children with ADs (7-17 years), and parents. Assessments were pre-, mid-, post-test, and 10 weeks after CBT (follow-up). Predictors (measured pre-treatment) were child characteristics (gender, age, type of AD, comorbid disorders), fathers' and mothers' anxious/depressive symptoms, and parental involvement (based on parents' presence during treatment sessions and the use of a parent module in treatment). At follow-up, 59% (intent-to-treat analyses) to 70% (completer analysis) of the children were free from their primary anxiety disorder. A significant decrease in anxiety symptoms was found. Higher parental involvement was related to lower child anxiety at follow-up, but only for children with comorbid disorders. Findings suggest that it is beneficial to treat anxiety with modular CBT. Future steps involve comparisons of modularized CBT with control conditions.

Clinical effectiveness of the psychological therapy Mental Health Intervention for Children with Epilepsy in addition to usual care compared with assessment-enhanced usual care alone: a multicentre, randomised controlled clinical trial in the UK

BACKGROUND

Mental health difficulties are common in children and young people with chronic health conditions, but many of those in need do not access evidence-based psychological treatments. The study aim was to evaluate the clinical effectiveness of integrated mental health treatment for children and young people with epilepsy, a common chronic health condition known to be associated with a particularly high rate of co-occurring mental health difficulties.

METHODS

We conducted a parallel group, multicentre, open-label, randomised controlled trial of participants aged 3-18 years, attending epilepsy clinics across England and Northern Ireland who met diagnostic criteria for a common mental health disorder. Participants were randomised (1:1; using an independent web-based system) to receive the Mental Health Intervention for Children with Epilepsy (MICE) in addition to usual care, or assessment-enhanced usual care alone (control). Children and young people in both groups received a full diagnostic mental health assessment. MICE was a modular psychological intervention designed to treat common mental health conditions in children and young people using evidence-based approaches such as cognitive behaviour therapy and behavioural parenting strategies. Usual care for mental health disorders varied by site but typically included referral to appropriate services. Participants, along with their caregivers, and clinicians were not masked to treatment allocation but statisticians were masked until the point of analysis. The primary outcome, analysed by modified intention-to-treat, was the parent-report Strengths and Difficulties Questionnaire (SDQ) at 6 months post-randomisation. The study is complete and registered with ISRCTN (57823197).

FINDINGS

1401 young people were potentially deemed eligible for study inclusion. Following the exclusion of 531 young people, 870 participants were assessed for eligibility and completed the SDQ, and 480 caregivers provided consent for study inclusion between May 20, 2019, and Jan 31, 2022. Between Aug 28, 2019, and Feb 21, 2022, 334 participants (mean ages 10·5 years [SD 3·6] in the MICE group vs 10·3 [4·0] in control group at baseline) were randomly assigned to an intervention using minimisation balanced by age, primary mental health disorder, diagnosis of intellectual disability, and autistic spectrum disorder at baseline. 168 (50%) of the participants were female and 166 (50%) were male. 166 participants were randomly assigned to the MICE group and 168 were randomly assigned to the control group. At 6 months, the mean SDQ difficulties for the 148 participants in the MICE group was 17·6 (SD 6·3) and 19·6 (6·1) for the 148 participants in the control group. The adjusted effect of MICE was -1·7 (95% CI -2·8 to -0·5; p=0·0040; Cohen's d, 0·3). 14 (8%) patients in the MICE group experienced at least one serious adverse event compared with 24 (14%) in the control group. 68% percent of serious adverse events (50 events) were admission due to seizures.

INTERPRETATION

MICE was superior to assessment-enhanced usual care in improving symptoms of emotional and behavioural difficulties in young people with epilepsy and common mental health disorders. The trial therefore shows that mental health comorbidities can be effectively and safely treated by a variety of clinicians, utilising an integrated intervention across ages and in the context of intellectual disability and autism. The evidence from this trial suggests that such a model should be fully embedded in epilepsy services and serves as a model for other chronic health conditions in young people.

FUNDING

UK National Institute for Health Research Programme Grants for Applied Research programme and Epilepsy Research UK Endeavour Project Grant.

Impact of trauma exposure and depression comorbidity on response to transdiagnostic behavioral therapy for pediatric anxiety and depression

By adolescence, two-thirds of youth report exposure to at least one traumatic event, yet the impact of trauma history is not routinely considered when evaluating the effect of psychotherapeutic interventions. Trauma may be a particularly important moderator of the effects of transdiagnostic therapies for emotional disorders, as trauma exposure is associated with risk for the development of comorbid depression and anxiety. The current study examined the history of trauma exposure and the presence of clinically significant depression as moderators of treatment outcomes in the Brief Behavioral Therapy (BBT) trial, the largest study of transdiagnostic psychotherapy for youth. Youths (age 8-16 years) were randomized to BBT (n = 89) based in pediatric primary care or assisted referral to outpatient community care (ARC; n = 86). Clinical response, functioning, anxiety symptoms, and depression symptoms were assessed at post-treatment (Week 16) and at follow-up (Week 32). A significant three-way interaction emerged between the treatment group, comorbid depression, and trauma exposure. BBT was broadly effective for 3/4 of the sample, but, for anxious-depressed youth with trauma exposure, BBT never significantly separated from ARC. Differences in outcome were not accounted for by other participant characteristics or by therapist-rated measures of alliance, youth engagement, or homework completion. Implications for models of learning and for intervention theory and development are discussed.

Is respiratory sinus arrhythmia a modifiable index of symptom change in cognitive behavioral therapy for youth? A pooled-data analysis of a randomized trial

OBJECTIVE

We evaluated whether respiratory sinus arrhythmia (RSA) reactivity and resting RSA-physiological markers reflecting the increase in heart rate with inspiration and decrease during expiration related to parasympathetic influence on the heart-are modifiable and predict symptom change during youth psychotherapy. Methods: Diverse youth (N = 158; ages 7-15; 48.1% female) received the Modular Approach to Therapy for Children and completed pre-treatment (pre), post-treatment (post), and 18-months postbaseline (18Mo) assessments. We measured resting RSA, RSA reactivity during stress induction, and psychopathology symptoms. Results: Pre-to-post and pre-to-18Mo, reactivity decreased, and resting RSA increased. Changes in reactivity and resting RSA, separately, did not predict reduced psychopathology. Yet, decreased reactivity combined with increased resting RSA predicted reduced psychopathology over time, suggesting that observed RSA changes were beneficial for some. Higher dosage of a module utilizing slow-breathing, muscle-relaxation, and imagery predicted greater pre-to-18Mo changes in reactivity and resting RSA, whereas a similar module with less emphasis on slow-breathing did not. Conclusions: Findings raise the possibility that youth reactivity and resting RSA could be modifiable during cognitive behavioral therapy and contribute to the amelioration of psychopathology. More studies are needed to determine whether resting RSA and RSA reactivity are modifiable indices of symptom change in slow-breathing practices and psychotherapy.

CLINICALTRIALS.GOV IDENTIFIER

NCT03153904, registered May 15, 2017.

Group-based parent training programme for children with neurological conditions: a feasibility study

OBJECTIVE AND DESIGN

This study aimed to determine the feasibility and effectiveness of a parent training programme for parents of children with neurological conditions and behaviours that challenge.

SETTING

Child and adolescent mental health service within a specialist children's hospital.

PARTICIPANTS

Parents of 31 children with neurological conditions and behaviours that challenge.

INTERVENTIONS

Parents attended a 6-week evidence-based behavioural parenting programme delivered in a group format, either face-to-face or remote.

MAIN OUTCOME MEASURES

Feasibility was determined by attendance rates. Effectiveness was analysed primarily using parent-reported measures of child behaviour (Strengths and Difficulties Questionnaire, Paediatric Quality of Life and Goal-Based Outcomes). Secondary measures of parental well-being were also reported (Brief Parental Self-Efficacy Scale, Depression Anxiety Stress Scale Short Form and Parental Sense of Competence). Paired t-tests or Wilcoxon rank-sum tests were conducted to analyse differences preintervention and postintervention.

RESULTS

The attendance rates for the face-to-face and remote groups were 80% and 79%, respectively. Medium to large effect sizes were reported for most measures of child behaviour and parental well-being. There were statistically significant improvements found postintervention in children's behaviour (p=0.014), quality of life (p<0.001), goal-based outcomes (p<0.001), parental self-efficacy (p<0.001) and parental anxiety (p=0.030). Anecdotal feedback showed that parents indicated the group format was acceptable.

CONCLUSIONS

The group parenting intervention for parents of children with heterogeneous neurological conditions and behaviours that challenge appears feasible and effective in improving child behaviour and parental well-being.

Principle-Guided Psychotherapy for Children and Adolescents (FIRST): study protocol for a randomized controlled effectiveness trial in outpatient clinics

BACKGROUND

Hundreds of youth psychotherapy randomized trials have generated scores of helpful empirically supported treatments (ESTs). However, the standardized structure of many ESTs and their focus on a single disorder or homogeneous cluster of problems may not be ideal for clinically referred youths who have comorbidity and whose treatment needs may shift from week to week. This concern has prompted development of flexible transdiagnostic, modular youth psychotherapies. One of these, designed for efficient training and implementation, is FIRST-a transdiagnostic intervention built on five empirically supported principles of change (i.e., feeling calm, increasing motivation, repairing thoughts, solving problems, and trying the opposite) and targeting common internalizing and externalizing youth mental health disorders and problems. FIRST has shown promise in improving youth mental health in three open trials. Now, in a more rigorous test, we seek to (1) conduct a randomized controlled trial comparing FIRST to usual care in real-world clinical practice settings; (2) examine a promising candidate mediator of change-regulation of negative emotions; and (3) explore variables that may influence clinicians' treatment implementation.

METHODS

This is an assessor-naïve randomized controlled effectiveness trial in youth outpatient community clinics in New England and Texas. Using double randomization, clinic-employed clinicians and treatment-referred youths (7-15 years old) are independently randomly allocated (1:1) to FIRST or usual care. We aim to recruit 212 youth participants, all referred through normal community pathways, with elevated symptoms of anxiety, depression, conduct problems, or post-traumatic stress. This study will test the effectiveness of FIRST compared to usual care on mental health outcomes, examine whether those outcomes are mediated by regulation of negative emotions, and explore clinician factors that may be associated with FIRST implementation and outcomes. Session recordings are coded to assess treatment fidelity.

DISCUSSION

This study will evaluate the effectiveness of FIRST in youth community mental health settings, relative to the care usually provided in those settings. If FIRST is found to be effective, it could offer an efficient and practical method to increase use of empirically supported treatment principles in real-world practice contexts.

TRIAL REGISTRATION

NIH Clinical Trials Registry, NCT04725721. Registered 27 January 2021, https://clinicaltrials.gov/ct2/show/study/NCT04725721.

Congruency of multimodal data-driven personalization with shared decision-making for StayFine: individualized app-based relapse prevention for anxiety and depression in young people

Tailoring interventions to the individual has been hypothesized to improve treatment efficacy. Personalization of target-specific underlying mechanisms might improve treatment effects as well as adherence. Data-driven personalization of treatment, however, is still in its infancy, especially concerning the integration of multiple sources of data-driven advice with shared decision-making. This study describes an innovative type of data-driven personalization in the context of StayFine, a guided app-based relapse prevention intervention for 13- to 21-year-olds in remission of anxiety or depressive disorders (n = 74). Participants receive six modules, of which three are chosen from five optional modules. Optional modules are Enhancing Positive Affect, Behavioral Activation, Exposure, Sleep, and Wellness. All participants receive Psycho-Education, Cognitive Restructuring, and a Relapse Prevention Plan. The personalization approach is based on four sources: (1) prior diagnoses (diagnostic interview), (2) transdiagnostic psychological factors (online self-report questionnaires), (3) individual symptom networks (ecological momentary assessment, based on a two-week diary with six time points per day), and subsequently, (4) patient preference based on shared decision-making with a trained expert by experience. This study details and evaluates this innovative type of personalization approach, comparing the congruency of advised modules between the data-driven sources (1-3) with one another and with the chosen modules during the shared decision-making process (4). The results show that sources of data-driven personalization provide complementary advice rather than a confirmatory one. The indications of the modules Exposure and Behavioral Activation were mostly based on the diagnostic interview, Sleep on the questionnaires, and Enhancing Positive Affect on the network model. Shared decision-making showed a preference for modules improving positive concepts rather than combating negative ones, as an addition to the data-driven advice. Future studies need to test whether treatment outcomes and dropout rates are improved through personalization.

Utilizing Soccer for Delivery of HIV and Substance Use Prevention for Young South African Men: 6-Month Outcomes of a Cluster Randomized Controlled Trial

Young men in South Africa face the intersecting epidemics of HIV, substance use and endemic poverty. We tested the effectiveness of a behavioral intervention using soccer training to reduce the cluster of risks associated with HIV and substance use. This cluster randomized controlled trial was conducted with men aged 18-29 years old in 27 neighborhoods in the townships of Cape Town, South Africa. Neighborhoods were randomized to receive for 6 months either: (1) Soccer League (SL; n = 18 neighborhoods, n = 778 men) who attended soccer three times weekly (72 sessions; 94% uptake, 45.5% weekly attendance rate), combined with an HIV/substance use, cognitive-behavioral intervention; or (2) a Control Condition (CC; n = 9; 415 men) who received educational materials and referrals at 3 month intervals. The primary outcome was the number of significant changes in a cluster of outcomes including HIV-related risks, substance abuse, employment/income, mental health, violence, and community engagement. There was only one significant difference on the rapid diagnostic tests for mandrax at 6 months, an insufficient number of changes to indicate a successful intervention. A group-based behavioral intervention was ineffective in addressing multiple risk behaviors among at-risk young men, similar to the findings of several recent soccer-related interventions. Early adulthood may be too late to alter well-established patterns of risk behaviors.Clinical Trial Registration This trial was prospectively registered on 24 November 2014 with ClinicalTrials.gov NCT02358226.

Does behavioural parent training reduce internalising symptoms (or not) among children with externalising problems? Systematic review and meta-analysis

Behaviour parent training (BPT) is known to effectively reduce child externalising problems. However, evidence for BPT to have secondary benefits for reducing internalising symptoms remains unclear. To address this, electronic databases (PsycINFO, MEDLINE, EMBASE, CINAHL, and SCOPUS) were systematically searched for studies examining internalising outcomes from BPT among children aged 2-12 years with clinically elevated externalizing problems. Outcomes for internalising problems following BPT were analysed by meta-analysis. Of 9105 studies identified, 24 studies met the eligibility criteria. Results from meta-analysis demonstrated a significant small treatment effect size (g = - 0.41) for reducing internalising symptoms immediately after treatment. Studies showed moderate heterogeneity (I² = 44%). Moderation analyses indicated that the overall treatment effect was robust against variations in treatment and study design characteristics. However, a review of individual study methods indicate that these results are limited by significant heterogeneity and limitations in clinical assessment. Overall, the results suggest that BPT programmes for reducing externalising problems have the potential to improve internalising outcomes, but that there is limited information to determine the reliability of these effects, highlighting the need for further investigation.

Efficacy of Emotion-Focused Parenting Programs for Children's Internalizing and Externalizing Symptoms: A Randomized Clinical Study

OBJECTIVE

Emotion-Focused Skills Training (EFST) is a 12-week parental program based on Emotion-Focused Therapy, developed to improve children and adolescents' mental health problems.

METHODS

In a randomized clinical dismantling study, including parents of 236 children and adolescents (ages 6-13, M_age 8.9, 60.6% boys, 95.8% Caucasian) with externalizing and/or internalizing problems within clinical range, we examined the efficacy of two versions of EFST: one experiential condition (n = 120) involving emotionally evocative techniques and two-chair interventions, and one psychoeducational only condition (n = 116) involving didactic teaching of emotion skills. Both groups received a 2-day group training and 6 hours of individual supervision. Outcomes were parent- and teacher-reported symptoms at baseline, posttreatment, and 4-, 8-, and 12-month follow-up. Analyses were conducted using multilevel growth curve modeling and Bayesian post hoc analysis.

RESULTS

EFST showed efficacy in reducing parent-reported externalizing (b = -1.72, p < .001, d = 1.0) and internalizing (b = -1.71, p < .001, d = 0.9) symptoms, and teacher-reported externalizing (b = -.96, p < .001, d = 0.4), but not internalizing (b = -.13, p > .05, d = 0.2) symptoms. Multilevel analyses showed nonsignificant differences between conditions (all p's > .05), although a Bayesian longitudinal sensitivity analysis indicated a better outcome for the experiential condition.

CONCLUSION

EFST showed efficacy in symptom reduction for children and adolescents with internalizing and externalizing symptoms. Outcomes were maintained over 12 months for both conditions, supporting EFST as a transdiagnostic parental approach for early intervention.

Higher treatment focus diffusion in Multisystemic Therapy is associated with less functional improvement over the course of treatment

PURPOSE

Treatment focus diffusion (TFD), dividing focus across multiple concerns during treatment, is common in public mental health care and differs from the more narrowly focused empirically supported treatments for youth reported in the literature. The present study examined whether and to what extent TFD is associated with youth functional improvement over the course of therapy.

METHOD

This study utilized multi-level modeling techniques to analyze 12 consecutive years of standardized routine clinical service data from youth receiving treatment in one of two intensive in-home service settings: (a) Multisystemic Therapy (MST; n = 776 youths, 99 therapists), an implemented evidence-based treatment based on ecological theories of behavior in which therapists work with the multiple systems a youth interacts with (school, community, family), and (b) a standards-based service (n = 1854 youth, 413 therapists). Both service settings operate in the context of a publicly funded mental health care system which serves youth and families who are typically from underserved and low-income backgrounds. Majority of youth in this sample identified as multi-ethnic and male, and they, on average, were approximately 13 years old with three co-occurring diagnoses.

RESULTS

A significant TFD by service format interaction on youth functional improvement (alone and in the overall model) and follow up simple effects indicated that higher TFD was associated with significantly poorer outcomes in MST. The parameter estimate for TFD on functional improvement in the standards-based service format was in the same direction, but not statistically significant.

CONCLUSION

Our findings suggest that maintaining a narrower treatment focus might be beneficial to clients, particularly in implemented evidence-based treatments. Likewise, TFD could be a helpful case monitoring tool for clinicians, supervisors, and systems leaders when reviewing intensive-in-home cases.

Examining the Process of Implementing a Three-Step Mental Health and Wellbeing System of Care for Children and Adolescents Across Multiple Community Settings

Mental health problems affect large numbers of young people. Integrated systems are required that can be applied in diverse settings to reach youth 'where they are'. We evaluated the process of implementing a three-step youth mental health and wellbeing system in diverse community settings according to three implementation outcomes: feasibility, penetration and acceptability. The study describes 49 applications of the 'Life-Fit-Learning system' designed to assess the mental health and wellbeing of youth (Assess step), provide feedback on assessment results (Reflect step), and connect them to resources and services proportionate to their needs (Connect step). Within a participatory research approach, 3798 administrations were conducted with youth between 9 and 18 years and 90 administrations were conducted with adults. Implementation was based on the four phases of the Quality Implementation Framework and was staged to integrate stakeholder and consumer feedback and experience gained from focus groups and two pilot phases before full implementation. Feasibility ratings of successful implementation ranged from 86.7 to 96.4% across applications and settings. High penetration rates were achieved. The Life-Fit-Learning system successfully reached 91.9% to 96% of youth with the Assess and Reflect steps and low intensity Connect step resources. Of those, 14.7% to 23% were identified at-risk for mental health problems and 93% to 97% of those at-risk youth additionally received Connect step co-delivered group-based programs (moderate intensity care) and/or individual treatment (high intensity care). Youth and parents reported high satisfaction across all steps and delivery modes. With strong collaboration, an integrated model of care can be delivered feasibly, effectively and satisfactorily to reach large numbers of young people across settings.

How low can you go? Examining the effects of brief online training and post-training consultation dose on implementation mechanisms and outcomes for measurement-based care

BACKGROUND

Initial training and ongoing post-training consultation (i.e., ongoing support following training, provided by an expert) are among the most common implementation strategies used to change clinician practice. However, extant research has not experimentally investigated the optimal dosages of consultation necessary to produce desired outcomes. Moreover, the degree to which training and consultation engage theoretical implementation mechanisms-such as provider knowledge, skills, and attitudes-is not well understood. This study examined the effects of a brief online training and varying dosages of post-training consultation (BOLT+PTC) on implementation mechanisms and outcomes for measurement-based care (MBC) practices delivered in the context of education sector mental health services.

METHODS

A national sample of 75 clinicians who provide mental health interventions to children and adolescents in schools were randomly assigned to BOLT+PTC or control (services as usual). Those in BOLT+PTC were further randomized to 2-, 4-, or 8-week consultation conditions. Self-reported MBC knowledge, skills, attitudes, and use (including standardized assessment, individualized assessment, and assessment-informed treatment modification) were collected for 32 weeks. Multilevel models were used to examine main effects of BOLT+PTC versus control on MBC use at the end of consultation and over time, as well as comparisons among PTC dosage conditions and theorized mechanisms (skills, attitudes, knowledge).

RESULTS

There was a significant linear effect of BOLT+PTC over time on standardized assessment use (b = .02, p < .01), and a significant quadratic effect of BOLT+PTC over time on individualized assessment use (b = .04, p < .001), but no significant effect on treatment modification. BOLT + any level of PTC resulted in higher MBC knowledge and larger growth in MBC skill over the intervention period as compared to control. PTC dosage levels were inconsistently predictive of outcomes, providing no clear evidence for added benefit of higher PTC dosage.

CONCLUSIONS

Online training and consultation in MBC had effects on standardized and individualized assessment use among clinicians as compared to services as usual with no consistent benefit detected for increased consultation dosage. Continued research investigating optimal dosages and mechanisms of these established implementation strategies is needed to ensure training and consultation resources are deployed efficiently to impact clinician practices.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05041517 . Retrospectively registered on 10 September 2021.

Modular-based psychotherapy (MoBa) versus cognitive-behavioural therapy (CBT) for patients with depression, comorbidities and a history of childhood maltreatment: study protocol for a randomised controlled feasibility trial

INTRODUCTION

In depression treatment, most patients do not reach response or remission with current psychotherapeutic approaches. Major reasons for individual non-response are interindividual heterogeneity of etiological mechanisms and pathological forms, and a high rate of comorbid disorders. Personalised treatments targeting comorbidities as well as underlying transdiagnostic mechanisms and factors like early childhood maltreatment may lead to better outcomes. A modular-based psychotherapy (MoBa) approach provides a treatment model of independent and flexible therapy elements within a systematic treatment algorithm to combine and integrate existing evidence-based approaches. By optimally tailoring module selection and application to the specific needs of each patient, MoBa has great potential to improve the currently unsatisfying results of psychotherapy as a bridge between disorder-specific and personalised approaches.

METHODS AND ANALYSIS

In a randomised controlled feasibility trial, N=70 outpatients with episodic or persistent major depression, comorbidity and childhood maltreatment are treated in 20 individual sessions with MoBa or standard cognitive-behavioural therapy for depression. The three modules of MoBa focus on deficits associated with early childhood maltreatment: the systems of negative valence, social processes and arousal. According to a specific questionnaire-based treatment algorithm, elements from cognitive behavioural analysis system of psychotherapy, mentalisation-based psychotherapy and/or mindfulness-based cognitive therapy are integrated for a personalised modular procedure.As a proof of concept, this trial will provide evidence for the feasibility and efficacy (post-treatment and 6-month follow-up) of a modular add-on approach for patients with depression, comorbidities and a history of childhood maltreatment. Crucial feasibility aspects include targeted psychopathological mechanisms, selection (treatment algorithm), sequence and application of modules, as well as training and supervision of the study therapists.

ETHICS AND DISSEMINATION

This study obtained approval from the independent Ethics Committees of the University of Freiburg and the University of Heidelberg. All findings will be disseminated broadly via peer-reviewed articles in scientific journals and contributions to national and international conferences.

TRIAL REGISTRATION NUMBER

DRKS00022093.

Primary aim results of a clustered SMART for developing a school-level, adaptive implementation strategy to support CBT delivery at high schools in Michigan

Background

Schools increasingly provide mental health services to students, but often lack access to implementation strategies to support school-based (and school professional [SP]) delivery of evidence-based practices. Given substantial heterogeneity in implementation barriers across schools, development of adaptive implementation strategies that guide which implementation strategies to provide to which schools and when may be necessary to support scale-up.

Methods

A clustered, sequential, multiple-assignment randomized trial (SMART) of high schools across Michigan was used to inform the development of a school-level adaptive implementation strategy for supporting SP-delivered cognitive behavioral therapy (CBT). All schools were first provided with implementation support informed by Replicating Effective Programs (REP) and then were randomized to add in-person Coaching or not (phase 1). After 8 weeks, schools were assessed for response based on SP-reported frequency of CBT delivered to students and/or barriers reported. Responder schools continued with phase 1 implementation strategies. Slower-responder schools (not providing ≥ 3 CBT components to ≥10 students or >2 organizational barriers identified) were re-randomized to add Facilitation to current support or not (phase 2). The primary aim hypothesis was that SPs at schools receiving the REP + Coaching + Facilitation adaptive implementation strategy would deliver more CBT sessions than SPs at schools receiving REP alone. Secondary aims compared four implementation strategies (Coaching vs no Coaching × Facilitation vs no Facilitation) on CBT sessions delivered, including by type (group, brief and full individual). Analyses used a marginal, weighted least squares approach developed for clustered SMARTs.

Results

SPs (n = 169) at 94 high schools entered the study. N = 83 schools (88%) were slower-responders after phase 1. Contrary to the primary aim hypothesis, there was no evidence of a significant difference in CBT sessions delivered between REP + Coaching + Facilitation and REP alone (111.4 vs. 121.1 average total CBT sessions; p = 0.63). In secondary analyses, the adaptive strategy that offered REP + Facilitation resulted in the highest average CBT delivery (154.1 sessions) and the non-adaptive strategy offering REP + Coaching the lowest (94.5 sessions).

Conclusions

The most effective strategy in terms of average SP-reported CBT delivery is the adaptive implementation strategy that (i) begins with REP, (ii) augments with Facilitation for slower-responder schools (schools where SPs identified organizational barriers or struggled to deliver CBT), and (iii) stays the course with REP for responder schools.

Trial registration

ClinicalTrials.gov, NCT03541317, May 30, 2018.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13012-022-01211-w.

Whose Outcomes Come Out? Patterns of Caregiver- and Youth-reported Outcomes Based on Caregiver-youth Baseline Discrepancies

OBJECTIVE

Discrepancies between caregiver and youth reports of emotional and behavioral symptoms are well-documented, with cross-informant correlations often falling in the low to moderate range. Studies have shown that caregiver-youth (dis)agreement in reporting of youth symptoms is related to treatment outcomes. However, commonly used methods for exploring reporter discrepancies (e.g., difference scores) are limited by their inability to assess discrepancies across multiple symptom domains simultaneously, and thus these previous findings do not explore multiple patterns of (dis)agreement.

METHOD

We used latent profile analysis (LPA) to identify subgroups of clinically referred youths based on patterns of caregiver- and youth-reported internalizing and externalizing symptoms for 174 caregiver-youth dyads. Longitudinal multilevel models were used to examine changes in weekly caregiver- and youth-reported internalizing symptoms, externalizing symptoms, and top problems for identified subgroups.

RESULTS

The LPA identified four latent subgroups: (a) Caregiver Internalizing (9%), (b) Caregiver Internalizing-Externalizing (45%), (c) Youth Internalizing (7%), and (d) Caregiver-Youth Internalizing-Externalizing (39%). Clinical outcomes varied across informants and subgroups. Significant improvements in caregiver- and youth-reported outcome measures were documented within the Caregiver Internalizing, Caregiver Internalizing-Externalizing, and Caregiver-Youth Internalizing-Externalizing subgroups. However, only youth-reported improvements were detected in the Youth Internalizing subgroup. The results show differences in treatment outcomes across caregiver-youth informant subgroups.

CONCLUSIONS

These findings suggest how youth and caregiver baseline data could provide guidance for clinicians in interpreting discrepant reporting and its relevance to change during treatment.

Assessing practical implementation of modular psychotherapy for youth in community-based settings using benchmarking

Background

Achieving high quality outcomes in a community context requires the strategic coordination of many activities in a service system, involving families, clinicians, supervisors, and administrators. In modern implementation trials, the therapy itself is guided by a treatment manual; however, structured supports for other parts of the service system may remain less well-articulated (e.g., supervision, administrative policies for planning and review, information/feedback flow, resource availability). This implementation trial investigated how a psychosocial intervention performed when those non-therapy supports were not structured by a research team, but were instead provided as part of a scalable industrial implementation, testing whether outcomes achieved would meet benchmarks from published research trials.

Method

In this single-arm observational benchmarking study, a total of 59 community clinicians were trained in the Modular Approach to Therapy for Children (MATCH) treatment program. These clinicians delivered MATCH treatment to 166 youth ages 6 to 17 naturally presenting for psychotherapy services. Clinicians received substantially fewer supports from the treatment developers or research team than in the original MATCH trials and instead relied on explicit process management tools to facilitate implementation. Prior RCTs of MATCH were used to benchmark the results of the current initiative. Client improvement was assessed using the Top Problems Assessment and Brief Problem Monitor.

Results

Analysis of client symptom change indicated that youth experienced improvement equal to or better than the experimental condition in published research trials. Similarly, caregiver-reported outcomes were generally comparable to those in published trials.

Conclusions

Although results must be interpreted cautiously, they support the feasibility of using process management tools to facilitate the successful implementation of MATCH outside the context of a formal research or funded implementation trial. Further, these results illustrate the value of benchmarking as a method to evaluation industrial implementation efforts. Plain Language Summary: Randomized effectiveness trials are inclusive of clinicians and cases that are routinely encountered in community-based settings, while continuing to rely on the research team for both clinical and administrative guidance. As a result, the field still struggles to understand what might be needed to support sustainable implementation and how interventions will perform when brought to scale in community settings without those clinical trial supports. Alternative approaches are needed to delineate and provide the clinical and operational support needed for implementation and to efficiently evaluate how evidence-based treatments perform. Benchmarking findings in the community against findings of more rigorous clinical trials is one such approach. This paper offers two main contributions to the literature. First, it provides an example of how benchmarking is used to evaluate how the Modular Approach to Therapy for Children (MATCH) treatment program performed outside the context of a research trial. Second, this study demonstrates that MATCH produced comparable symptom improvements to those seen in the original research trials and describes the implementation strategies associated with this success. In particular, although clinicians in this study had less rigorous expert clinical supervision as compared with the original trials, clinicians were provided with process management tools to support implementation. This study highlights the importance of evaluating the performance of intervention programs when brought to scale in community-based settings. This study also provides support for the use of process management tools to assist providers in effective implementation.

Anger Responses in Adolescents: Relationship with Punishment and Reward Sensitivity

A substantial proportion of youth with anxiety disorders shows comorbid behavioral (anger) problems. Such comorbid profile is associated with low treatment effectiveness and negative (longterm) outcomes. This study was therefore designed to examine trait factors that may promote anger responding in adolescents. By presenting participants (N = 158, mean age = 15.7, 56% female) with a series of common anger-eliciting situations, we tested whether high reward sensitivity would be associated with anger via perceived non-reward, and high punishment sensitivity via perceived threat. In line with the hypotheses, an indirect effect of reward sensitivity on anger was found via perceived non-reward, and an indirect effect of punishment sensitivity on anger via perceived threat. The latter association also had an indirect effect via perceived non-reward. High punishment and reward sensitivity may thus set adolescents at risk for developing (comorbid) anger problems via heightened threat and non-reward perceptions.

Evidence-Based Treatments in Community Mental Health Settings: Use and Congruence With Children's Primary Diagnosis and Comorbidity

Many evidence-based treatments (EBTs) have been identified for specific child mental health disorders, but there is limited research on the use of EBTs in community-based settings. This study used administrative data from a statewide system of care to examine 1) the extent to which EBTs were provided congruent with the child's primary diagnosis, 2) whether there were differences in effectiveness of EBTs that were congruent or incongruent with the child's primary diagnosis, and 3) whether comorbidity moderated the effectiveness of EBTs for children based on congruence with their primary diagnosis. The sample consisted of 23,895 children ages 3-17 with at least one of the most common diagnoses (attention-deficit/hyperactivity disorder, conduct problems, depressive disorders, anxiety disorders, and post-traumatic stress disorder) who received outpatient psychotherapy. Data were collected as part of routine care, including child demographic characteristics, diagnosis, treatment type, and problem severity. Forty-two percent of children received an EBT congruent with their diagnosis, and these children showed greater improvement than the 35% of children who received no EBT (ES = 0.14-0.16) or the 23% who received an EBT incongruent with their diagnosis (ES = 0.06-0.15). For children with comorbid diagnoses, the use of EBTs congruent with the primary diagnosis was also associated with the greatest improvement, especially when compared to no EBT (ES = 0.22-0.24). Results of the current study support the use of EBTs in community-based settings, and suggest that clinicians should select EBTs that match the child's primary diagnosis to optimize treatment outcomes, especially for children with comorbidity.

Relative Effectiveness of CBT-Components and Sequencing in Indicated Depression Prevention for Adolescents: A Cluster-Randomized Microtrial

OBJECTIVE

Cognitive Behavioral Therapy (CBT) was dismantled into four modules of three sessions each: cognitive restructuring (Think), behavioral activation (Act), problem solving (Solve) and relaxation (Relax). We investigated the modules' relative effectiveness in indicated depression prevention for adolescents and examined variations in sequencing of these modules.

METHOD

We performed a pragmatic cluster-randomized microtrial with four parallel conditions: (1) Think-Act-Relax-Solve (n = 14 clusters, n = 81 participants); (2) Act-Think-Relax-Solve (n = 13, n = 69); (3) Solve-Act-Think-Relax (n = 13, n = 77); and (4) Relax-Solve-Act-Think (n = 12, n = 55). The sample consisted of 282 Dutch adolescents with elevated depressive symptoms (M_age = 13.8; 55.7% girls, 92.9% Dutch). In total 52 treatment groups were randomized as a cluster. Assessments were conducted at baseline, after each module and at 6-month follow-up with depressive symptoms as primary outcome.

RESULTS

None of the modules (Think, Act, Solve, Relax) was associated with a significant decrease in depressive symptoms after three sessions and no significant differences in effectiveness were found between the modules. All sequences of modules were associated with a significant decrease in depressive symptoms at post-intervention, except the sequence Relax-Solve-Act-Think. At 6-month follow-up, all sequences showed a significant decrease in depressive symptoms. No significant differences in effectiveness were found between the sequences at post-intervention and 6-month follow-up.

CONCLUSIONS

Regardless of the CBT technique provided, one module of three sessions may not be sufficient to reduce depressive symptoms. The sequence in which the CBT components cognitive restructuring, behavioral activation, problem solving and relaxation are offered, does not appear to significantly influence outcomes at post- intervention or 6-month follow-up.

ABBREVIATIONS

CDI-2:F: Children's Depression Inventory-2 Full-length version; CDI-2:S: Children's Depression Inventory-2 Short version; STARr: Solve, Think, Act, Relax and repeat.

Addressing anhedonia to increase depression treatment engagement

Anhedonia, or reward system dysfunction, is associated with poorer treatment outcomes among depressed individuals. The role of anhedonia in treatment engagement, however, has not yet been explored. We review research on components of reward functioning impaired in depression, including effort valuation, reward anticipation, initial responsiveness, reward learning, reward probability, and reward delay, highlighting potential barriers to treatment engagement associated with these components. We then propose interventions to improve treatment initiation and continuation by addressing deficits in each component of reward functioning, focusing on modifications of existing evidence-based interventions to meet the needs of individuals with heightened anhedonia. We describe potential settings for these interventions and times at which they can be delivered during the process of referring individuals to mental health treatment, conducting intakes or assessments, and providing treatment. Additionally, we note the advantages of using screening processes already in place in primary care, workplace, school, and online settings to identify individuals with heightened anhedonia who may benefit from these interventions. We conclude with suggestions for future research on the impact of anhedonia on treatment engagement and the efficacy of interventions to address it. PRACTITIONER POINTS: Many depressed individuals who might benefit from treatment do not initiate it or discontinue early. One barrier to treatment engagement may be anhedonia, a core symptom of depression characterized by loss of interest or pleasure in usual activities. We describe brief interventions to improve treatment engagement in individuals with anhedonia that can be implemented during the referral process or early in treatment. We argue that interventions aiming to improve treatment engagement in depressed individuals that target anhedonia may be particularly effective.

"A greatest hits compilation of mental health support": A qualitative study of health professionals' perceptions of modular CBT in pediatric epilepsy services

OBJECTIVES

The primary aim of this qualitative study was to explore the views of health professionals, with little previous clinical mental health training, of an adapted modular cognitive-behavioral intervention (MATCH-ADTC) for common mental health problems in children and young people with epilepsy.

METHODS

Healthcare Professionals (HCPs) and their supervisors were interviewed at the start (n = 23) and end (n = 15) of the six-month training period. The interviews were transcribed verbatim and analyzed using thematic analysis.

RESULTS

Three higher order themes with sub-themes were identified: (1) strengths of the MATCH-ADTC content and manual; (2) expectations of the treatment; and (3) improving practice with MATCH-ADTC. Overall impressions of the training and treatment were largely positive, with HCPs viewing MATCH-ADTC as an acceptable treatment for the families that they worked with. HCPs highlighted some challenges in delivering an integrated service, particularly relating to the time commitment involved and their own confidence in delivering the intervention, as many participants did not have a mental health background.

CONCLUSIONS

The findings suggested that the intervention and training was acceptable to HCPs working in pediatric epilepsy services, and confidence grew over the six-month training period. Further research is needed to understand how to best train, supervise, and support HCPs in pediatric epilepsy services to deliver mental health treatments.

"Third-wave" cognitive and behavioral therapies and the emergence of a process-based approach to intervention in psychiatry

For decades, cognitive and behavioral therapies (CBTs) have been tested in randomized controlled trials for specific psychiatric syndromes that were assumed to represent expressions of latent diseases. Although these protocols were more effective as compared to psychological control conditions, placebo treatments, and even active pharmacotherapies, further advancement in efficacy and dissemination has been inhibited by a failure to focus on processes of change. This picture appears now to be evolving, due both to a collapse of the idea that mental disorders can be classified into distinct, discrete categories, and to the more central attention given to processes of change in newer, so-called "third-wave" CBTs. Here we review the context for this historic progress and evaluate the impact of these newer methods and models, not as protocols for treating syndromes, but as ways of targeting an expanded range of processes of change. Five key features of "third-wave" therapies are underlined: a focus on context and function; the view that new models and methods should build on other strands of CBT; a focus on broad and flexible repertoires vs. an approach to signs and symptoms; applying processes to the clinician, not just the client; and expanding into more complex issues historically more characteristic of humanistic, existential, analytic, or system-oriented approaches. We argue that these newer methods can be considered in the context of an idiographic approach to process-based functional analysis. Psychological processes of change can be organized into six dimensions: cognition, affect, attention, self, motivation and overt behavior. Several important processes of change combine two or more of these dimensions. Tailoring intervention strategies to target the appropriate processes in a given individual would be a major advance in psychiatry and an important step toward precision mental health care.

Core Elements of Family Therapy for Adolescent Behavioral Health Problems: Validity Generalization in Community Settings

OBJECTIVE

The core elements of family therapy for adolescent mental health and substance use problems, originally distilled from high-fidelity sessions conducted by expert clinicians, were tested for validity generalization when delivered by community therapists in routine settings.

METHOD

The study sampled recorded sessions from 161 cases participating in one of three treatment pools: implementation trial of Functional Family Therapy (98 sessions/50 cases/22 therapists), adaptation trial of Multisystemic Therapy (115 sessions/59 cases/2 therapists), and naturalistic trial of non-manualized family therapy in usual care (107 sessions/52 cases/21 therapists). Adolescents were identified as 60% male and 40% female with an average age of 15.4 years; 49% were Latinx, 27% White Non-Latinx, 15% African American, 3% another race/ethnicity, 6% race/ethnicity unknown. Session recordings (n = 320) were randomly selected for each case and coded for 21 discrete family therapy techniques. Archived data of one-year clinical outcomes were gathered.

RESULTS

Confirmatory factor analyses replicated the factor structure from the original distillation study, retaining all four clinically coherent treatment modules comprised of all 21 techniques: Interactional Change (ICC = .77, Cronbach's α = .81); Relational Reframe (ICC = .75, α = .81); Adolescent Engagement (ICC = .72, α = .78); Relational Emphasis (ICC = .76, α = .80). Exploratory analyses found that greater use of core techniques predicted symptom improvements in one treatment pool.

CONCLUSIONS

Core techniques of family therapy distilled from manualized treatments for adolescent behavioral health problems showed strong evidence of validity generalization, and initial evidence of links to client outcomes, in community settings.

The value of a modular, multi-focal, therapeutic approach to addressing child maltreatment: Hope for Children and Families Intervention Resources - a discussion article

This discussion article begins by highlighting two trends apparent in the field of child maltreatment. The first, an awareness that multiple forms of maltreatment - polyvictimization - is the rule in populations of abused and neglected children rather than the exception. The second is that current types of child maltreatment are being extended to include Adverse Childhood Experiences (ACEs). These include intra-familial violence, mental health, substance misuse, and inter-generational abuse. The paper introduces an innovative strategy to help the field better organise and prevent the extensive sequelae of polyvictimization and ACEs. This strategy involves the development of a modular approach, which identifies common treatment elements and common factors across the field of effective interventions and organizes them, providing a co-ordinated framework for practitioners to use to address the diverse needs of children and families when vulnerability or maltreatment are identified. The development of this approach, the Hope for Children and Families (HfCF) Intervention Resources, is described using a case example to illustrate its logic and structure. Findings from the HFCF pilot and subsequent training programs suggest that this new approach could be an important milestone in the protection of children from violence, abuse and neglect on the 30th Anniversary of the United Nation's Convention on the Rights of the Child (1989).

Randomized Controlled Trial of an Integrated Family-Based Treatment for Adolescents Presenting to Community Mental Health Centers

Most adolescents presenting to community mental health centers have one or more comorbidities (internalizing, externalizing, and substance use problems). We evaluated an integrated family-based outpatient treatment for adolescents (OPT-A) that can be delivered in a community mental health center by a single therapist. A sample of 134 youth/families were randomized to receive OPT-A or usual services, delivered at the same public sector mental health center. Repeated, multi-informant assessments occurred through 18-months post-baseline. At baseline, the sample displayed low internalizing symptoms, moderate substance use, and high externalizing problems. Compared to usual services, OPT-A had effects on abstinence rates, retention, motivation, parent involvement, and satisfaction, but not on internalizing or externalizing problems. While OPT-A achieved some key improvements for youth who present to community mental health centers, and families were satisfied with treatment, continued work is necessary to examine treatments for comorbidity while balancing treatment feasibility and complex strategies to boost treatment effectiveness.

A Modular, Transdiagnostic Approach to Treating Severe Irritability in Children and Adolescents

Severe irritability is common in treatment-referred youth, often occurring in externalizing, anxiety, and mood conditions. The best available evidence indicates behavioral parent training and cognitive-behavioral therapy as first-line interventions. Modular approaches (eg, MATCH) can package these strategies in a flexible format, facilitating personalization. Ample evidence supports MATCH's effectiveness generally and initial evidence supports its effectiveness for irritability specifically. We provide an overview of MATCH and its application to severe irritability. Emphasis is placed on behavioral parent training as a likely primary/first-line treatment. Potential benefits and limitations are considered. This approach calls for careful clinical judgment and for further empirical research.

Psychotherapy outcome research: Implications of a new clinical taxonomy

Since the publication of DSM-III in 1980, the scientist-practitioner gap in clinical psychology has expanded, as almost all outcome research in clinical psychology has been on diagnosed mental disorders within a medical model using drug trial methodologies, whereas most practising clinicians undertake functional analyses and case formulations of clinical psychological problems (CPPs) and then apply tailored interventions within an ongoing hypothesis-testing methodology. But comparatively reliable assessment and generalizable conclusions in psychotherapy outcome research require a comprehensive theory-derived conception or operational definition of 'CPPs', standardized functional analyses, and a taxonomy of CPPs comparable to DSM's listings of mental disorders. An alternative conception and taxonomy of CPPs have recently been proposed, offering improvements in the reliability and generalizability of case formulation-based psychotherapy outcome research. It conceives of CPPs as instances of the formation and operation of self-sustaining problem-maintaining circles (PMCs) of psychological-level causal elements-that is, at the level of cognitions, behaviours, emotions, and events or situations (stimuli). The paper describes this new conception of CPPs, a subsequent nascent taxonomy of evidence-based PMCs which standardizes the underlying mechanisms that maintain CPPs, and ensuing benefits to research (as well as to practice) in clinical psychology. These benefits include being able to encompass all treatment-worthy CPPs, not just diagnosable mental disorders; to assess theory-derived intervention strategies, not just arbitrary therapy bundles; and to directly feed back into psychological theories, not just expand an atheoretical list of patented "evidence supported therapies."

Treatment Refractory Internalizing Behaviour Across Disorders: An Aetiological Model for Severe Emotion Dysregulation in Adolescence

Auto-aggressive behaviour, especially treatment refractory suicidality in adolescents with psychiatric disorders, may be challenging to clinicians. In search of therapeutic possibilities, we have integrated current opinions regarding causality and interdependency of suicidality and auto-aggressive behaviour across disorders within the HiTOP framework. We propose a developmental model regarding these unsettling behaviours in youths that may help to guide future directions for research and interventions. We argue that the interdependent development of biologic factors, attachment, moral reasoning and emotion regulation in an overprotective environment may lead to social anxiety and later during development to emotion dysregulation and severe internalizing behaviour disorders. To optimize treatment efficacy for both internalizing and externalizing behaviour, we emphasize the importance transdiagnostic interventions, such as addressing non-compliance, restoration of trust between parents and their child, and limitation of avoidance behaviour. These may be seen as higher order interventions within the HiTOP framework.

Evaluating a Modular Approach to Therapy for Children With Anxiety, Depression, Trauma, or Conduct Problems (MATCH) in School-Based Mental Health Care: Study Protocol for a Randomized Controlled Trial

Introduction: Schools have become a primary setting for providing mental health care to youths in the U.S. School-based interventions have proliferated, but their effects on mental health and academic outcomes remain understudied. In this study we will implement and evaluate the effects of a flexible multidiagnostic treatment called Modular Approach to Therapy for Children with Anxiety, Depression, Trauma, or Conduct Problems (MATCH) on students' mental health and academic outcomes.

Methods and Analysis: This is an assessor-blind randomized controlled effectiveness trial conducted across five school districts. School clinicians are randomized to either MATCH or usual care (UC) treatment conditions. The target sample includes 168 youths (ages 7–14) referred for mental health services and presenting with elevated symptoms of anxiety, depression, trauma, and/or conduct problems. Clinicians randomly assigned to MATCH or UC treat the youths who are assigned to them through normal school referral procedures. The project will evaluate the effectiveness of MATCH compared to UC on youths' mental health and school related outcomes and assess whether changes in school outcomes are mediated by changes in youth mental health.

Ethics and Dissemination: This study was approved by the Harvard University Institutional Review Board (IRB14-3365). We plan to publish the findings in peer-reviewed journals and present them at academic conferences.

Clinical Trial Registration:ClinicalTrials.gov ID: NCT02877875. Registered on August 24, 2016.

Effectiveness of Transdiagnostic Cognitive-Behavioral Psychotherapy Compared With Management as Usual for Youth With Common Mental Health Problems: A Randomized Clinical Trial

IMPORTANCE

Behavioral therapy and cognitive-behavioral therapy (CBT) programs targeting a single class of problems have not been widely implemented. The population of youths with common mental health problems is markedly undertreated.

OBJECTIVE

To determine the effectiveness of a new transdiagnostic CBT program (Mind My Mind [MMM]) compared with management as usual (MAU) in youths with emotional and behavioral problems below the threshold for referral to mental health care.

DESIGN, SETTING, AND PARTICIPANTS

This pragmatic, multisite, randomized clinical trial of MMM vs MAU was conducted from September 7, 2017, to August 28, 2019, including 8 weeks of postintervention follow-up, in 4 municipalities in Denmark. Consecutive help-seeking youths were randomized (1:1) to the MMM or the MAU group. Main inclusion criteria were age 6 to 16 years and anxiety, depressive symptoms, and/or behavioral disturbances as a primary problem. Data were analyzed from August 12 to October 25, 2019.

INTERVENTIONS

The MMM intervention consisted of 9 to 13 weekly, individually adapted sessions of manualized CBT delivered by local psychologists. The MAU group received 2 care coordination visits to enhance usual care.

MAIN OUTCOMES AND MEASURES

The primary outcome was change in mental health problems reported by parents at week 18, using the Strengths and Difficulties Questionnaire (SDQ) Impact scale (range, 0-10 points, with higher scores indicating greater severity of distress and impairment). Primary and secondary outcomes were assessed in the intention-to-treat population at week 18. Maintenance effects were assessed at week 26.

RESULTS

A total of 396 youths (mean [SD] age, 10.3 [2.4] years; 206 [52.0%] boys) were randomized to MMM (n = 197) or MAU (n = 199), with primary outcome data available in 177 (89.8%) and 167 (83.9%), respectively, at 18 weeks. The SDQ Impact score decreased by 2.34 points with MMM and 1.23 with MAU, from initial scores of 4.12 and 4.21, respectively (between-group difference, 1.10 [95% CI, 0.75-1.45]; P < .001; Cohen d = 0.60). Number of responders (≥1-point reduction in SDQ Impact score) was greater with MMM than with MAU (144 of 197 [73.1%] vs 93 of 199 [46.7%]; number needed to treat, 4 [95% CI, 3-6]). Secondary outcomes indicated statistically significant benefits in parent-reported changes of anxiety, depressive symptoms, daily functioning, school attendance, and the principal problem. All benefits were maintained at week 26 except for school attendance.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, the scalable transdiagnostic cognitive-behavioral intervention MMM outperformed MAU in a community setting on multiple, clinically relevant domains in youth with emotional and behavioral problems.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT03535805.

M.I.C.E-Mental Health Intervention for Children with Epilepsy: a randomised controlled, multi-centre clinical trial evaluating the clinical and cost-effectiveness of MATCH-ADTC in addition to usual care compared to usual care alone for children and young people with common mental health disorders and epilepsy-study protocol

BACKGROUND

Mental health disorders in the context of long-term conditions in children and young people are currently overlooked and undertreated. Evidence-based psychological treatments for common childhood mental health disorders (anxiety, depression and disruptive behaviour disorders) have not been systematically evaluated in young people with epilepsy despite their high prevalence in this population. The aim of this multi-site randomised controlled trial is to determine the clinical and cost-effectiveness of adding a modular psychological intervention to usual care for the mental health disorders in comparison to assessment-enhanced usual care alone.

METHODS

In total, 334 participants aged 3-18 years attending epilepsy services will be screened for mental health disorders with the Strengths and Difficulties Questionnaire (SDQ) and the diagnostic Development and Wellbeing Assessment (DAWBA). Those identified as having a mental health disorder and consenting to the trial will be randomised to either receive up to 22 sessions of the modular psychological intervention (MATCH-ADTC) delivered over the telephone over 6 months by non-mental health professionals in addition to usual care or to assessment-enhanced usual care alone. Outcomes will be measured at baseline, 6 months and 12 months post-randomisation. It is hypothesised that MATCH-ADTC plus usual care will be superior to assessment-enhanced usual care in improving emotional and behavioural symptoms. The primary outcome is the SDQ reported by parents at 6 months. Secondary outcomes include parent-reported mental health measures such as the Revised Children's Anxiety and Depression Scale, quality of life measures such as the Paediatric Quality of Life Inventory and physical health measures such as the Hague Seizure Severity Scale. Outcome assessors will be blinded to group assignment. Qualitative process evaluations and a health economic evaluation will also be completed.

DISCUSSION

This trial aims to determine whether a systematic and integrated approach to the identification and treatment of mental health disorders in children and young people with epilepsy is clinically and cost-effective. The findings will contribute to policies and practice with regard to addressing mental health needs in children and young people with other long-term conditions.

TRIAL REGISTRATION

ISRCTN ISRCTN57823197 . Registered on 25 February 2019.

Tackling Mental Health in Youth Sporting Programs: A Pilot Study of a Holistic Program

Linking mental health services to organised sport offers an avenue to identify and improve mental health among adolescents. In this study, we investigated the efficacy, acceptability and feasibility of an integrated mental health system embedded within a junior sports development program. A three-step integrated mental health program for 12- to 15-year-old rugby league players (N = 74) was delivered in urban (n = 44) and rural (n = 33) areas. Specifically, this system (a) assessed participant mental health on primary outcome measures of anxiety, depression, and anger/conduct problems (and secondary outcome measures of personal attributes and relationships), (b) provided feedback to participants, parents and program coordinators, and (c) connected participants and parents to a multi-component intervention including online resources, a group-based workshop program (4 × 30-min sessions), and tailored individual-level follow-up and referral to further care for participants at high risk of mental health problems. From pre- to post-program, boys' anxiety symptoms declined significantly (with only a trend-level reduction in depression), and there were significant improvements in grit (for urban boys only), efficacy to manage negative emotions, and prosocial behaviour. In addition, when boys reported symptoms associated with high risk for mental health problems, providing parents with feedback enhanced boys' access to care and was associated with significant declines in anxiety symptoms. The program was generally acceptable and feasible, with very high retention in the youth sports development program. Overall, early findings support further deployment and evaluation of integrated mental health systems embedded within sporting contexts to address mental health problems among adolescent boys.

Cognitive behavioural therapy for anxiety disorders in children and adolescents

BACKGROUND

Previous Cochrane Reviews have shown that cognitive behavioural therapy (CBT) is effective in treating childhood anxiety disorders. However, questions remain regarding the following: up-to-date evidence of the relative efficacy and acceptability of CBT compared to waiting lists/no treatment, treatment as usual, attention controls, and alternative treatments; benefits across a range of outcomes; longer-term effects; outcomes for different delivery formats; and amongst children with autism spectrum disorders (ASD) and children with intellectual impairments.

OBJECTIVES

To examine the effect of CBT for childhood anxiety disorders, in comparison with waitlist/no treatment, treatment as usual (TAU), attention control, alternative treatment, and medication.

SEARCH METHODS

We searched the Cochrane Common Mental Disorders Controlled Trials Register (all years to 2016), the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and PsycINFO (each to October 2019), international trial registries, and conducted grey literature searches.

SELECTION CRITERIA

We included randomised controlled trials of CBT that involved direct contact with the child, parent, or both, and included non-CBT comparators (waitlist/no treatment, treatment as usual, attention control, alternative treatment, medication). Participants were younger than age 19, and met diagnostic criteria for an anxiety disorder diagnosis. Primary outcomes were remission of primary anxiety diagnosis post-treatment, and acceptability (number of participants lost to post-treatment assessment), and secondary outcomes included remission of all anxiety diagnoses, reduction in anxiety symptoms, reduction in depressive symptoms, improvement in global functioning, adverse effects, and longer-term effects.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures as recommended by Cochrane. We used GRADE to assess the quality of the evidence.

MAIN RESULTS

We included 87 studies and 5964 participants in quantitative analyses. Compared with waitlist/no treatment, CBT probably increases post-treatment remission of primary anxiety diagnoses (CBT: 49.4%, waitlist/no treatment: 17.8%; OR 5.45, 95% confidence interval (CI) 3.90 to 7.60; n = 2697, 39 studies, moderate quality); NNTB 3 (95% CI 2.25 to 3.57) and all anxiety diagnoses (OR 4.43, 95% CI 2.89 to 6.78; n = 2075, 28 studies, moderate quality). Low-quality evidence did not show a difference between CBT and TAU in post-treatment primary anxiety disorder remission (OR 3.19, 95% CI 0.90 to 11.29; n = 487, 8 studies), but did suggest CBT may increase remission from all anxiety disorders compared to TAU (OR 2.74, 95% CI 1.16 to 6.46; n = 203, 5 studies). Compared with attention control, CBT may increase post-treatment remission of primary anxiety disorders (OR 2.28, 95% CI 1.33 to 3.89; n = 822, 10 studies, low quality) and all anxiety disorders (OR 2.75, 95% CI 1.22 to 6.17; n = 378, 5 studies, low quality). There was insufficient available data to compare CBT to alternative treatments on post-treatment remission of primary anxiety disorders, and low-quality evidence showed there may be little to no difference between these groups on post-treatment remission of all anxiety disorders (OR 0.89, 95% CI 0.35 to 2.23; n = 401, 4 studies) Low-quality evidence did not show a difference for acceptability between CBT and waitlist/no treatment (OR 1.09, 95% CI 0.85 to 1.41; n=3158, 45 studies), treatment as usual (OR 1.37, 95% CI 0.73 to 2.56; n = 441, 8 studies), attention control (OR 1.00, 95% CI 0.68 to 1.49; n = 797, 12 studies) and alternative treatment (OR 1.58, 95% CI 0.61 to 4.13; n=515, 7 studies). No adverse effects were reported across all studies; however, in the small number of studies where any reference was made to adverse effects, it was not clear that these were systematically monitored. Results from the anxiety symptom outcomes, broader outcomes, longer-term outcomes and subgroup analyses are provided in the text. We did not find evidence of consistent differences in outcomes according to delivery formats (e.g. individual versus group; amount of therapist contact time) or amongst samples with and without ASD, and no studies included samples of children with intellectual impairments.

AUTHORS' CONCLUSIONS

CBT is probably more effective in the short-term than waiting lists/no treatment, and may be more effective than attention control. We found little to no evidence across outcomes that CBT is superior to usual care or alternative treatments, but our confidence in these findings are limited due to concerns about the amount and quality of available evidence, and we still know little about how best to efficiently improve outcomes.

Latent class analysis of post-traumatic stress symptoms and complex PTSD in child victims of sexual abuse and their response to Trauma-Focused Cognitive Behavioural Therapy

Background: PTSD symptoms are frequent in child victims of sexual abuse. Yet, authors have argued that early trauma could lead to alterations in development that go far beyond the primary symptoms of PTSD and have proposed Complex PTSD as an alternative diagnosis encompassing difficulties in affect regulation, relationships and self-concept. Objective: To delineate profiles in child victims of sexual abuse and explore whether profiles are associated with treatment response to Trauma-Focused Cognitive Behavioural Therapy. Method: Latent class analysis was used to identify symptom profiles at baseline assessment of 384 children ages 6 to 14, recruited in a Child Advocacy Centre following disclosure of sexual abuse. Dimensions of Complex PTSD diagnosis as proposed by the ICD-11 were derived from self-report questionnaires. Results: Latent class analysis identified a best fitting model of three classes: Classic PTSD regrouping 51% of children, Complex PTSD describing 23% of children, and Resilient describing 25% of children. Trauma-focused therapy was associated with a significant reduction of dissociation, internalizing, and externalizing problems for children of all three classes. Trauma-focused therapy was also linked to a significant reduction of PTSD symptoms with larger effect size (d = .90; 95%CI: 0.63-1.16) for children classified in the Complex PTSD class. Conclusion: These findings highlight the utility of a person-oriented approach to enhance our understanding of the diversity of profiles in child victims. The results offer empirical support for the ICD-11 PTSD and Complex PTSD distinction in a clinical sample of sexually abused children and the relevance of this distinction in foreseeing treatment outcomes.

ADHD in Adolescents: Commentary on the Special Issue of Ripple Effects in Self-Perceptions and Social Relationships

Adolescence is a developmental period that affords both risk as well as enormous opportunity. Ripple effects can extend far and wide and speak to the nuance and complexity in understanding and treating ADHD during the adolescent period. The studies in this special issue provide novel and important insights into the lives of adolescents with ADHD, and they collectively point to important areas for both research and clinical attention. Further, each of the studies underscore the importance of soliciting the perspective of adolescents with ADHD. In this commentary, I consider the value of self-report when working with adolescents with ADHD, the possibility of a self-perception bias in youth with ADHD, challenges in assessing social functioning in adolescence, and implications for school-based assessments and interventions. For treatment specifically, I raise the possibility of a modular intervention approach for adolescents with ADHD and shared decision making that solicits and incorporates the adolescent perspective. The voices of adolescents with ADHD may be crucial for understanding how to lower risk, promote resilience, reduce stigma, and improve our assessments and interventions.

Toward precision therapeutics: general and specific factors differentiate symptom change in depressed adolescents

BACKGROUND

The longitudinal course of multiple symptom domains in adolescents treated for major depression is not known. Revealing the temporal course of general and specific psychopathology factors, including potential differences between psychotherapies, may aid therapeutic decision-making.

METHODS

Participants were adolescents with major depressive disorder (aged 11-17; 75% female; N = 465) who were part of the IMPACT trial, a randomized controlled trial comparing cognitive behavioral therapy, short-term psychoanalytic psychotherapy, and brief psychosocial intervention. Self-reported symptoms at baseline and 6, 12, 36, 52, and 86 weeks postrandomization were analyzed with bifactor modeling.

RESULTS

General psychopathology factor scores decreased across treatment and one-year follow-up. Specific melancholic features and depressive cognitions factors decreased from baseline to 6 weeks. Conduct problems decreased across treatment and follow-up. Anxiety increased by 6 weeks and then reverted to baseline levels. Obsessions-compulsions did not change. Changes in general and specific factors were not significantly different between the three psychotherapies during treatment. During follow-up, however, conduct problems decreased more in brief psychosocial intervention versus cognitive behavioral therapy (1.02, 95% Bayes credible interval 0.25, 1.96), but not versus short-term psychoanalytic psychotherapy.

CONCLUSIONS

The clinical response signature in this trial is best revealed by rapid reductions in depression symptoms and general psychopathology. Protracted improvements in general psychopathology and conduct problems subsequently occur. Psychosocial treatments for adolescent depression have comparable effects on general and specific psychopathology, although a psychoeducational, goal-focused approach may be indicated for youth with comorbid conduct problems.

Beyond the Lab: Empirically Supported Treatments in the Real World

Laboratory studies of empirically supported treatments (ESTs) for mental health problems achieve much higher rates of clinical improvement than has been observed following treatment in the community. This discrepancy is likely to due to limited reliance on ESTs by therapists outside of academia. Concerns about the generalizability of ESTs to patients in the community, who may have comorbid problems, likely limit rates of adoption. The present study examined the impact of ESTs delivered in the real-world for 1,256 adults who received services through an employee assistance program specializing in the delivery of ESTs. Rates of anxiety and depression decreased significantly, following treatment with an EST, and 898 (71.5%) patients demonstrated reliable improvement. Even among patients comorbid for depression and anxiety at baseline, over half reported reliable improvement in both disorders. Findings suggest ESTs can be effectively delivered outside of academic RCTs. However, additional research is needed to understand and overcome barriers to disseminating ESTs to the broader community.

Systematic Review and Meta-analysis: Outcomes of Routine Specialist Mental Health Care for Young People With Depression and/or Anxiety

OBJECTIVE

Depression and anxiety are the most prevalent mental health problems in youth, yet almost nothing is known about what outcomes are to be expected at the individual level following routine treatment. This paper sets out to address this gap by undertaking a systematic review of outcomes following treatment as usual (TAU) with a particular focus on individual-level outcomes.

METHOD

MEDLINE, Embase and PsycInfo were searched for articles published between 1980 and January 2019 that assessed TAU outcomes for youth depression and anxiety accessing specialist mental health care. Meta-analysis considered change at both group-level pre-post effect size (ES) and individual-level recovery, reliable change, and reliable recovery. Temporal analysis considered stability of primary and secondary outcomes over time. Subgroup analysis considered the moderating effect of informant; presenting problem; study design; study year; mean age of youth; use of medication; intervention dosage and type of treatment offered on outcomes. A protocol was preregistered on PROSPERO (CRD42017063914).

RESULTS

Initial screening of 6,350 publications resulted in 38 that met the inclusion criteria, and that were subsequently included in meta-analyses. This resulted in a final full pooled sample of 11,739 young people (61% of whom were female, mean age 13.8 years). The pre-post ES (Hedges' g) at first/final outcome (13/26 weeks) was -0.74/-0.87. The individual-level change on measures of self-report was 38% reliable improvement, 44% no reliable change, and 6% reliable deterioration. Outcomes varied according to moderators, informant, problem type and dosage.

CONCLUSION

Poor data quantity and quality are limitations, but this is the first study that indicates likely rates of reliable improvement for those accessing TAU. We propose the need for improved reporting of both individual-level metrics and details of TAU to enable greater understanding of likely current outcomes from routine care for youths with depression and anxiety in order to allow the potential for further improvement of impact.

Optimising Evidence-Based Psychological Treatment for the Mental Health Needs of Children with Epilepsy: Principles and Methods

There are potent evidence-based psychological treatments for youth with mental health needs, yet they are rarely implemented in clinical practice, especially for youth with mental health disorders in the context of chronic physical illness such as epilepsy. Implementation science, the study of the translation of research into practice, can promote the uptake of existing effective interventions in routine clinical practice and aid the sustainable integration of psychological treatments with routine health care. The aim of this report was to use four implementation science methods to develop a version of an existing effective psychological treatment for mental health disorders [the Modular Approach to Treatment of Children with Anxiety, Depression or Conduct Problems (MATCH-ADTC)] for use within paediatric epilepsy services: (a) literature search; (b) iterative focus groups underpinned by normalisation process theory; (c) Plan-Do-Study-Act methods; and (d) qualitative patient interviews. Findings: Three modifications were deemed necessary to facilitate implementation in children with both mental health disorders and epilepsy. These were (a) a universal brief psychoeducational component addressing the relationship between epilepsy and mental health; (b) supplementary, conditionally activated interventions addressing stigma, parental mental health and the transition to adulthood; and (c) additional training and supervision. The intervention needed relatively little alteration for implementation in paediatric epilepsy services. The modified treatment reflected the scientific literature and the views of clinicians and service users. The multi-method approach used in this report can serve as a model for implementation of evidence-based psychological treatments for children with mental health needs in the context of other chronic illnesses.

A typology of useful evidence: approaches to increase the practical value of intervention research

BACKGROUND

Too often, studies of evidence-based interventions (EBIs) in preventive, community, and health care are not sufficiently useful to end users (typically practitioners, patients, policymakers, or other researchers). The ways in which intervention studies are conventionally conducted and reported mean that there is often a shortage of information when an EBI is used in practice. The paper aims to invite the research community to consider ways to optimize not only the trustworthiness but also the research's usefulness in intervention studies. This is done by proposing a typology that provides some approaches to useful EBIs for intervention researchers. The approaches originate from different research fields and are summarized to highlight their potential benefits from a usefulness perspective.

MAIN MESSAGE

The typology consists of research approaches to increase the usefulness of EBIs by improving the reporting of four features in intervention studies: (1) the interventions themselves, including core components and appropriate adaptations; (2) strategies to support-high-quality implementation of the interventions; (3) generalizations about the evidence in a variety of contexts; and (4) outcomes based on end users' preferences and knowledge. The research approaches fall into three levels: Description, Analysis, and Design. The first level, Description, outlines what types of information about the intervention and its implementation, context, and outcomes can be helpful for end users. Research approaches under analysis offers alternative ways of analyzing data, increasing the precision of information provided to end users. Approaches summarized under design involve more radical changes and far-reaching implications for how research can provide more useful information. These approaches partly flip the order of efficacy and effectiveness, focusing not on whether an intervention works in highly controlled and optimal circumstances, but first and foremost whether an intervention can be implemented and lead to anticipated outcomes in everyday practice.

CONCLUSIONS

The research community, as well as the end users of research, are invited to consider ways to optimize research's usefulness as well as its trustworthiness. Many of the research approaches in the typology are not new, and their contributions to quality have been described for generations - but their contributions to useful knowledge need more attention.

Self-reported and parent proxy reported functional impairment among pediatric cancer survivors and controls

Background

A unique and limiting component in the research on functional impairment among children has been the exclusive use of parent proxy reports about child functioning; and there is limited information regarding the impact of pediatric cancer treatment on children’s day-to-day functioning and how this is related to neurocognitive functioning. The objective of the current study was to examine a novel measure of self-reported functional impairment, and explore the relationship between self-reported and parent-reported child functional impairment in pediatric cancer survivors compared to controls.

Methods

A cross-sectional cohort of survivors (n = 26) and controls (n = 53) were recruited. Survivors were off treatment an average of 6.35 years (SD = 5.38; range 1–15 years) and demonstrated an average “medium” Central Nervous System treatment intensity score. Participants completed measures of functional impairment (FI), intellectual assessment (RIST) and executive functions (NIH Examiner), while parents reported on children’s functional impairment.

Results

Survivors were similar to controls in functional impairment. Regardless of group membership, self-reported FI was higher than parent-reported FI, although they were correlated and parent report of FI significantly predicted self-reported FI. Across groups, increased impairment was associated with four of seven Examiner scores.

Conclusions

Research regarding self-reported functional impairment of cancer survivors and its association with parent-reported functional impairment and neurocognitive deficits has been limited. Our results suggest that self-reported FI appears to be a reasonable and viable outcome measure that corresponds with and adds incremental validity to parent reported FI. While low treatment intensity may confer relative sparing of functional impairment among survivors, children report higher FI levels than parents, suggesting that FI can be of clinical utility. In conclusion, pediatric cancer survivors should be screened for self-reported functional difficulties.

Utilizing broad-based partnerships to design a precision approach to implementing evidence-based home visiting

The aim of this paper is to describe a participatory process for adapting an implementation strategy, using a precision approach, for an evidence-based home visiting program, Family Spirit. Family Spirit serves Native American and low-income communities nationwide. To redesign Family Spirit's implementation strategy, we used workshops (n = 5) with key stakeholders and conducted an online survey with implementers (n = 81) to identify hypothesized active ingredients and "pivot points" to guide when to tailor the program and for whom. Active ingredients identified included the relationship between the home visitor and clients, lessons ensuring child safety and healthy development, parent-child communication, and goal setting. Pivot points included whether the client is a first-time mother who has substance abuse history, has a baby at risk for childhood obesity, and/or has sexual or reproductive health concerns. These results are informing the adaptation of Family Spirit' implementation strategy making it more responsive to diverse families while balancing fidelity to the previously proven standard model.

Feasibility of decision rule-based treatment of comorbid youth: A pilot randomized control trial

This study examined the feasibility, acceptability, and preliminary efficacy of a decision rule driven treatment for youth with comorbid conduct problems and depression. A randomized, controlled, repeated measures design was used to compare two treatment approaches: Decision-Rule Based Treatment (DR) and Sequential Treatment (SEQ). Participants included 30 children (ages 8-14; 66% female; 80% Caucasian) who met criteria for a depressive disorder (major depressive disorder and/or dysthymia) and a conduct problem disorder (oppositional defiant disorder and/or conduct disorder). Assessments were conducted at baseline, post-treatment, and six-month follow-up. Treatment adherence, attendance, and session evaluations ratings indicate that the treatments were feasible to implement and acceptable to parents and youth in both conditions. Both treatments showed similar remission of internalizing and externalizing diagnoses. Participants in DR showed significantly greater improvements at six-month follow-up in child-reported depressive symptom severity compared to SEQ. Both DR and SEQ conditions showed significantly lower behavior problems at end of treatment and six-month follow-up. DR showed significant reductions in emotion dysregulation at 6-month follow-up, while SEQ did not. Findings suggest that a decision rule based intervention holds promise as a feasible and acceptable treatment with high rates of remittance.

Turning Back to Treatment: The Effect of Attendance and Symptom Outcomes on Subsequent Service Use

This study explored whether post-treatment symptom severity moderated the association between session attendance during an initial treatment episode and subsequent mental health service use. Data on attendance, symptom severity, and service use were gathered from an effectiveness trial testing a modular treatment for youth anxiety, depression, disruptive behavior, and traumatic stress. Multilevel logistic regression analyses showed a significant interaction between attendance and post-treatment symptom severity on subsequent service use, such that attendance significantly predicted subsequent service use when post-treatment symptom severity was in the normal range. Implications regarding the influence of treatment engagement on future help-seeking are discussed.

Enhancing patient and organizational readiness for cardiovascular risk reduction among Black and Latinx patients living with HIV: Study protocol

Cardiovascular disease (CVD) is an increasingly important cause of morbidity and mortality among people living with HIV (PLWH) now that HIV is a manageable chronic disease. Identification and treatment of comorbid medical conditions for PLWH, including CVD and its risk factors, typically lack a critical component of care: integrated care for histories of trauma. Experiences of trauma are associated with increased HIV infection, CVD risk, inconsistent treatment adherence, and poor CVD outcomes. To address this deficit among those at greatest risk and disproportionately affected by HIV and trauma-i.e., Black and Latinx individuals-a novel culturally-congruent, evidence-informed care model, "Healing our Hearts, Minds and Bodies" (HHMB), has been designed to address patients' trauma histories and barriers to care, and to prepare patients to engage in CVD risk reduction. Further, in recognition of the need to ensure that PLWH receive guideline-concordant cardiovascular care, implementation strategies have been identified that prepare providers and clinics to address CVD risk among their Black and Latinx PLWH. The focus of this paper is to describe the hybrid Type 2 effectiveness/implementation study design, the goal of which is to increase both patient and organizational readiness to address trauma and CVD risk among 260 Black and Latinx PLWH recruited from two HIV service organizations in Southern California. This study is expected to produce important information regarding the value of the HHMB intervention and implementation processes and strategies designed for use in implementing HHMB and other evidence-informed programs in diverse, resource-constrained treatment settings, including those that serve patients living in deep poverty. Clinical trials registry: NCT04025463.