Barriers to and Facilitators in the Implementation of Cognitive-Behavioral Therapy for Youth Anxiety in the Community

Are the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents as Effective for OCD as for Anxiety and Depression?

Background: Obsessive-compulsive disorder (OCD) in youth commonly co-occurs with other affective disorders (e.g., anxiety, depression). Exposure and response prevention (ERP) is the front-line treatment for OCD but may require significant adaptation to treat co-occurring symptoms or complex comorbidity patterns. Preliminary evidence suggests that the Unified Protocols for Transdiagnostic Treatment of Emotional Disorders in Children and Adolescents (UP-C/A) are effective in reducing OCD symptoms. Still, it is not yet known if the UP-C/A are comparably effective to treat OCD as they are for anxiety and depression, the disorders for which there is the most robust empirical support. Methods: This study compared trajectories of OCD, anxiety, and depression symptom change among 388 youth who received UP-C/A treatment (M = 15 sessions) at a university-based research clinic. We also examined whether youth with (n = 60) and without (n = 328) an OCD diagnosis demonstrated comparable improvements in anxiety, depression, and transdiagnostic treatment targets (i.e., anxiety sensitivity, cognitive flexibility, and distress tolerance). Results: OCD symptoms improved at a slower rate than anxiety and depression symptoms during the first half of UP-C/A treatment but at a comparable rate to anxiety and depression symptoms during the second half of treatment. Youth with and without OCD exhibited comparable improvements in anxiety, depression, anxiety sensitivity, cognitive flexibility, and distress tolerance across the treatment course. Conclusions: Findings support the efficacy of UP-C/A treatment for co-occurring OCD and affective disorders but suggest that initiating exposure earlier in the treatment course may confer additional benefits.

Implementation of Transdiagnostic Psychosocial Group Interventions and a Novel Peer Work Role in a Community Youth Mental Health Setting

AIMS

Group interventions can be an appropriate care option for young people with mental ill-health, yet there is a lack of research on their implementation within real-world settings. This paper aimed to explore the feasibility and acceptability of group interventions and a Group Coordinator peer work role in a community mental health service and the perspectives of young people, carers and staff on implementation.

METHODS

A retrospective chart audit of 121 referrals to group interventions from January 2022 to June 2023 was conducted. Education, demographic and administrative data were collected to explore feasibility and acceptability. Survey data from 44 young people who participated was also used to explore acceptability. Semi-structured interviews (8 young people, 7 carers and 11 staff) explored perspectives on implementation, mapping barriers and facilitators to domains of the Comprehensive Framework for Implementation Research.

RESULTS

Referrals made before the young person was involved in mental health treatment (i.e., at the stage of assessment) were less likely to result in engagement in a group, suggesting limited feasibility as a standalone care option. Young people reported overall positive experiences of group interventions, though attrition rates and qualitative interviews indicate they are perceived as less acceptable than individual options. The Group Coordinator role was viewed by staff as key to sustainability, with multiple benefits.

CONCLUSIONS

The current paper contributes to the scant literature on the implementation of group interventions with several practical implications for service planning. Further studies are needed to examine the implementation in other contexts, explore within-treatment variables and incorporate clinical outcomes.

Australian Clinicians' Capabilities, Opportunities, and Motivations in Implementing Exposure and Response Prevention for Youth with Obsessive-Compulsive Disorder: An Exploratory Study

Objectives: Informed by implementation science, this exploratory study examined the capabilities, opportunities, and motivations of Australian mental health clinicians (N = 38) associated with the implementation of exposure and response prevention (ERP) for youth (i.e., children and adolescents) with obsessive-compulsive disorder (OCD). It also explored how the capabilities and motivations of mental health clinicians untrained in ERP for youth (i.e., typical clinicians; n = 25) differed from clinicians experienced in the use of ERP for youth (i.e., experienced clinicians; n = 13). Methods: Questionnaires were administered to the entire sample alongside observational role-plays, which assessed observed adherence and competence delivering ERP against published best-practice standards among available participants. Results: In the whole sample, the reported time dedicated to implementing ERP was associated with a range of factors relating to capabilities, opportunities, and motivations to implement ERP. Experienced clinicians had greater knowledge, adherence, competence, and self-reported confidence using ERP and fewer negative beliefs about ERP relative to typical clinicians. They also intended to dedicate greater time to implementing within-session ERP for youth and reported greater within- and between-session time spent doing so compared to typical clinicians. The time intended to dedicate to implementing between-sessions ERP did not significantly differ between the clinician groups. Conclusions: In summary, compared to typical clinicians, experienced clinicians appeared to possess greater levels of capabilities and motivations to implement ERP for youth with OCD. Future research examining barriers and facilitators of ERP implementation in community settings and identifying effective strategies to improve it would benefit service provision and, ultimately, outcomes for youth.

Brief Interventions for Anxiety

Brief, nonpharmacological interventions for anxiety are often defined as no more than 10 sessions or 50% contact time of a full intervention. Brief interventions can be of high or low intensity, depending on the type and extent of therapist support provided, and may be concentrated. There is evidence to support the use of brief cognitive-behavioral interventions for anxiety in mental health clinics, primary care, and schools, and internet delivery can be a cost-effective alternative to standard formats. Research to identify cases requiring longer and/or more intense intervention is needed to inform stepped-care approaches to improving treatment access.

From plan to practice: A qualitative study of public mental health therapists' session-planning practices

Therapists must dedicate considerable time to session plan to implement evidence-based practices (EBPs) flexibly and with fidelity. It is unclear whether public mental health settings offer the structural and organizational support for therapists to engage in session planning and, therefore, whether they provide the necessary infrastructure for EBP implementation. In Fall 2022, 18 therapists working in public mental health settings in New York City were recruited through snowball sampling to participate in 90-min semistructured qualitative interviews. Therapists were prompted to review their session-planning practices using a chart-stimulated recall strategy; to describe structural, organizational, and individual barriers and facilitators to session planning; and to generate recommendations to support their session planning. Qualitative data were analyzed using thematic analysis. A diverse group of therapists participated in the study-22% identified as Black; 22% as Asian; and 11% as Hispanic/Latinx. Seventy-eight percent of therapists were social workers; and they had on average 6.18 (SD = 5.70) years of clinical experience. The research team identified four multilevel session-planning barriers and three multilevel session-planning facilitators. Therapists proposed seven multilevel recommendations to support their session planning. Overall, therapists indicated that managing high productivity standards, severe clinical presentations, and clients' social needs often prevent them from having time to plan for sessions. Efforts to implement EBPs in public mental health settings cannot neglect the structural realities faced by agencies, therapists, and clients. Multilevel resources and reforms to support therapists' session planning are necessary. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

What Really Matters in the Implementation of Evidence-based Practices in Community Mental Health? Insight and Recommendations from Experts, Providers, and Clients

Perceptions of evidence-based practices (EBPs) and implementation are inherent drivers of implementation outcomes. Most studies on implementation perceptions have focused on direct service providers, but clients and EBP experts may offer additional meaningful information about implementing EBPs in community settings. EBP providers (n = 21), EBP experts (n = 12), and clients who received EBPs (n = 6) participated in focus groups to ascertain their perceptions of and experiences with EBP implementation, as part of a program evaluation. Thematic analysis indicated that provider and expert perceptions of EBP implementation in community settings converged around themes of implementation supports and training and client outcomes, along with several subthemes. Client perceptions centered on themes regarding the importance of their personal experiences, their impressions of EBPs, as well as their recommendation for increasing public awareness and use of EBPs. Findings suggest that the perspectives of EBP providers and experts are closely aligned, focusing on system-level, individual-level, and training issues that impact EBP implementation within a public mental health system. The themes that were important to clients were primarily related to their experiences as recipients of an EBP which produced insightful recommendations for promoting EBPs in the community.

Providing a new transdiagnostic emotion-focused pain treatment in a clinical context: therapists' experiences of facilitators and barriers

Providing new psychological treatments in clinical settings requires implementation strategies adapted to the organizational context. This study explored how licensed psychologists experienced their context when providing a new transdiagnostic psychological treatment, "the hybrid treatment", to treat comorbid pain and emotional problems in a clinical setting. We aimed to identify which contextual factors the therapists experienced as facilitating or hindering, to gain a better understanding of important considerations when planning a future implementation strategy. Contextual factors were identified using the Consolidated Framework of Implementation Research (CFIR) in data collection and analysis. Data were collected through semi-structured interviews (N = 9). Thematic analysis resulted in the identification of five main influencing factors: Perception of the intervention's adaptability, prioritization of the patient's needs, leadership engagement, structure for collaboration, and therapists' professional engagement. The results highlight the importance of ensuring a clearly stated mandate for the key individuals involved. The findings may guide future implementation of new psychological treatments into regular care, to enhance facilitators and overcome barriers.

Training Community Therapists in AIM HI: Individual Family and Neighborhood Factors and Child/Caregiver Outcomes

OBJECTIVE

Publicly funded mental health services play an important role in caring for children with mental health needs, including children with autism spectrum disorder (ASD). This study assessed the associations between individual family- and neighborhood-level sociodemographic factors and baseline family functioning and long-term outcomes when community therapists were trained to deliver An Individualized Mental Health Intervention for ASD (AIM HI).

METHOD

Participants included 144 children with ASD (ages 5 to 13 years; 58.3% Latinx) and their caregivers whose therapists received AIM HI training within a cluster-randomized effectiveness-implementation trial in publicly funded mental health services. Sociodemographic strain (e.g., low income, less education, single-parent status, minoritized status) was coded at the individual family and neighborhood level, and caregivers rated caregiver strain at baseline. Child interfering behaviors and caregiver sense of competence were assessed at baseline and 6-, 12- and 18-months after baseline.

RESULTS

Higher caregiver strain was associated with higher intensity of child behaviors (B = 5.17, p < .001) and lower caregiver sense of competence (B = -6.59, p < 001) at baseline. Child and caregiver outcomes improved over time. Higher caregiver strain (B = 1.50, p < .001) and lower family sociodemographic strain (B = -0.58, p < .01) were associated with less improvements in child behaviors. Lower caregiver strain (B = -2.08, p < .001) and lower neighborhood sociodemographic strain (B = -0.51, p < .01) were associated with greater improvements in caregiver sense of competence.

CONCLUSIONS

Findings corroborate the importance of considering both family and neighborhood context in the community delivery of child-focused EBIs.

TRIAL REGISTRATION

Clinical Trials NCT02416323.

Determinants of Exposure Therapy Implementation in Clinical Practice for the Treatment of Anxiety, OCD, and PTSD: A Systematic Review

Exposure therapy (ET) forms a vital part of effective psychotherapy for anxiety-related presentations including anxiety disorders, obsessive-compulsive disorder (OCD), and post-traumatic stress disorder (PTSD), and is often underutilised in clinical practice. Using the Theoretical Domains Framework (TDF), this systematic review synthesised existing literature on the determinants of ET implementation for anxiety-related presentations and examined differences across presentations and developmental subgroups. Fifty-two eligible studies were assessed using the Mixed Methods Appraisal Tool, with 389 results (99%) mapped onto the TDF. Results suggested that clinicians' negative beliefs about the consequences of ET were commonly associated with reduced implementation. It also appeared that whilst broad unspecified ET training may be related to improved implementation for anxiety disorders; greater implementation for complex presentations (i.e., PTSD) likely requires more specialised training involving practical components. A subset of domains (e.g., social/professional role and identity) accounted for most results, whilst some remain unexplored (i.e., optimism; reinforcement; memory, attention, and decision processes) or underexplored (i.e., behavioural regulation). Likewise, specific presentations and developmental subgroups (i.e., PTSD and adults) represented a greater proportion of results in the literature than others (i.e., OCD and youth). Future research exploring ET implementation, across specific presentations and developmental subgroups, would benefit from integrating implementation science frameworks to guide the development of targeted, comprehensive strategies to close the research-practice gap of ET for the treatment of anxiety-related presentations.

Better together? A randomized controlled microtrial comparing different levels of therapist and parental involvement in exposure-based treatment of childhood specific phobia

INTRODUCTION

Exposure is often limited to homework assignments in routine clinical care. The current study compares minimally-guided (MGE) and parent-guided (PGE) out-session homework formats to the 'golden standard' of therapist-guided in-session exposure with minimally-guided exposure at home (TGE).

METHODS

Children with specific phobia (N = 55, age 8-12, 56% girls) participated in a single-blind, randomized controlled microtrial with a four-week baseline-treatment period design. Clinical interviews, behavioral avoidance tests, and self-report measures were assessed at pre-treatment, post-treatment, and at one-month follow-up.

RESULTS

TGE resulted in a larger decline of specific phobia severity from baseline to post-treatment compared to MGE but not compared to PGE. Parental anxiety was found to be a moderator of less treatment efficacy of PGE from baseline to post-treatment. Overall, there was no meaningful difference in efficacy of TGE versus MGE or PGE from baseline to follow-up.

CONCLUSIONS

These findings suggest that for improving short-term treatment gains, exposure exercises can best be conducted with the help of a therapist within the therapy session before they are conducted as homework assignments outside the therapy session. However, for long-term treatment gains exposure exercises can be handled by the child itself or with help of its parents.

Facilitators and Barriers to the Implementation of a School-Based Intervention for Anxiety

School-based cognitive behavioural interventions for anxiety are found to be effective, but there is a lack of research on their implementation in real world settings. The current study aims to explore the facilitators and barriers to the implementation of a school-based intervention for anxiety through a qualitative process evaluation. Evaluation of the implementation of Let's Introduce Anxiety Management (LIAM), a six-session school-based cognitive behavioural intervention, was conducted. LIAM was implemented by non-mental health professionals trained and coached on the model. Semi-structured interviews with stakeholders (N = 15) were analysed with grounded theory and framework analysis. Forty-one practitioners were trained and coached on LIAM, with thirty-five children and young people receiving the intervention. Facilitators (e.g. systemic collaboration, self-efficacy and an enabling context) and barriers (e.g. the exclusivity of the intervention and a lack of systemic understanding) to implementation emerged as themes. Implementing school-based interventions is complex and requires the involvement of multiple stakeholders.

Barriers to and facilitators of using evidence-based, cognitive-behavioral anxiety interventions in integrated primary care practice

Cognitive-behavioral treatment for anxiety disorders and symptoms remains underutilized in integrated primary care (IPC), in part because the many treatments developed for specialty care are not readily translated to this unique setting. The objective of this study was to identify barriers and facilitators to behavioral health providers (BHPs) delivering evidence-based cognitive--behavioral anxiety interventions within IPC practice. We conducted semistructured interviews with a national sample of 18 BHPs (50% psychologists, 33% social workers, 17% registered nurses) working in IPC in the Veterans Health Administration. We assessed barriers to and facilitators of using psychoeducation, exposure, cognitive therapy, relaxation training, mindfulness/meditation, Acceptance and Commitment Therapy-based interventions, and problem-solving therapy. Qualitative coding and conventional content analysis revealed barriers and facilitators at three levels: IPC, provider, and patient. Themes suggested key barriers of poor fit with the IPC model, BHP training deficits, and lack of patient buy-in, and key facilitators of good perceived fit of the intervention (e.g., scope, duration) with the IPC model, BHPs feeling well equipped, and utility for patients. BHPs select interventions based on fit for the individual patient. Some results were consistent with prior work from specialty care, but the IPC model itself introduces significant implementation challenges. BHPs would benefit from flexible intervention options and training on IPC treatment goals and how to deliver the essence of evidence-based interventions in small doses. Our findings will help to inform adaptation of behavioral anxiety interventions to better fit IPC practice and development of beneficial training and resources for BHPs to reduce implementation challenges. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

Enhancing Quality of Care Through Evidence-Based Practice: Training and Supervision Experiences

OBJECTIVE

Evidence-based practice (EBP) is the preferred approach to treatment in mental health settings because it involves the integration of the best available research, clinical expertise, and patient values to optimize patient outcomes. Training on empirically supported treatments (ESTs) in mental health settings is an important component of EBP, and supervision of therapists' implementation of ESTs is critical for therapists to develop and maintain a strong EBP skill set. This study aimed to evaluate training and supervision histories of therapists in outpatient and inpatient psychiatric care settings as an essential first step in improving patient outcomes.

METHODS

Electronic surveys were completed by 69 therapists, most of whom had a master's degree, within a psychiatry and behavioral sciences department at an academic institution. Participating therapists were recruited from several outpatient and inpatient mental health settings serving children, adolescents, and adults.

RESULTS

Although most therapists reported completing some form of EST-related coursework, a majority did not receive any supervision related to implementation of ESTs (51% for cognitive-behavioral therapy cases, 76% for dialectical behavior therapy cases, and 52% for other EST cases) during graduate and postgraduate training.

CONCLUSIONS

Although research from the past decade has supported the need for improvements in training on ESTs, and especially in supervision, problems related to limited exposure to training and supervision among therapists still exist. These findings have implications for how mental health centers can evaluate staff members' EST training and supervision experiences, training needs, and associated training targets to improve the quality of routine care.

Ginseng and Ginseng Herbal Formulas for Symptomatic Management of Fatigue: A Systematic Review and Meta-Analysis

Objectives: Ginseng has been widely used in fatigue management. However, its efficacy on fatigue remains unclear. This study aimed to assess the efficacy and safety of ginseng and ginseng herbal formulas for fatigue in randomized clinical trials (RCTs). Methods: The authors searched PubMed, Embase, Cochrane, Web of Science, and Allied and Complementary Medicine Database (AMED) databases from inception to July 6, 2022. Outcomes included fatigue severity, quality of life (QoL), and adverse events (AEs). Quality of evidence was assessed using the Cochrane Risk of Bias Tool. They pooled all included data and performed subgroup analysis by fatigue type, assessment instrument, and ginseng type. Results: The authors included 19 RCTs. Pooled analyses found no significant reduction in fatigue severity with ginseng versus controls (standardized mean difference [SMD]: -0.36, 95% confidence interval [CI]: -0.82 to 0.11, p = 0.13). In subgroup analysis, there was significant fatigue reduction with the ginseng herbal formula (SMD: -0.39, 95% CI: -0.66 to -0.13, p = 0.004) and chronic fatigue (CF) (SMD: -0.30, 95% CI: -0.56 to -0.03, p = 0.03) compared to controls. Ginseng produced significant reductions in general (i.e., non-disease-specific) fatigue compared to controls (SMD: -0.48, 95% CI: -0.71 to -0.25, p < 0.0001). Ginseng was associated with a trend toward QoL improvement (p = 0.05) and did not increase AEs compared with controls. Effect sizes were small. Conclusion: Ginseng herbal formulas improved fatigue severity compared to controls, especially among patients with CF, but with a small effect size. Rigorous RCTs as well as guidelines for standard ginseng usage are needed to further evaluate the effects of ginseng for fatigue and ensure proper use.

The Effect of an Adapted Digital Mental Health Intervention for Sickle Cell Disease on Engagement: A Pilot Randomized Controlled Trial

INTRODUCTION

Despite promising outcomes, lack of engagement and poor adherence are barriers to treating mental health using digital CBT, particularly in minority groups. After conducting guided focus groups, a current mental health app was adapted to be more inclusive for minorities living with SCD.

METHODS

Patients between the ages of 16-35 with SCD who reported experiencing anxiety or depression symptoms were eligible for this study. Once enrolled, participants were randomly assigned to receive one of two versions of a mental health app 1) the current version designed for the general population and 2) the adapted version. Baseline measures for depression, anxiety, pain and self-efficacy were completed at the start of the study and again at postintervention (minimum 4 weeks).

RESULTS

Compared to baseline, pain (p = 0.03), self-efficacy (p = 0.007) and depression symptoms (p = 0.016) improved for the group that received the adapted app. Regardless of group assignment, a positive relationship (r = 0.47) was shown between app engagement and a change in depression symptoms (p = 0.042).

DISCUSSION

Target enrollment for this study sought to enroll 40 participants. However, after difficulties locating qualified participants, enrollment criteria were adjusted to expand the population pool. Regardless of these efforts, the sample size for this study was still smaller than anticipated (n = 21). Additionally, irrespective of group approximately 40% of participants did not engage with the app. However, despite a small sample size and poor engagement, participants in the intervention group displayed better outcomes and showed trends for greater app interaction.

CONCLUSION

These promising results should encourage future researchers to continue exploring ideal adaptations for implementing digital CBT in minority populations. Future studies should also consider implementing post-intervention surveys to help identify common factors relating to a lack of engagement.

Therapist perceptions of experiential training for exposure therapy

BACKGROUND

Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use.

AIMS

This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training.

METHOD

Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use.

RESULTS

Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures.

DISCUSSION

Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

Adapting CBT for youth anxiety: Flexibility, within fidelity, in different settings

Anxiety disorders are common in youth, associated with impairments in daily functioning, and often persist into adulthood when untreated. Cognitive behavioral therapy (CBT) for youth anxiety is a well-established intervention and has been modified to fit several treatment settings. Despite decades of results supporting the efficacy of CBT, there is a large gap in access to this treatment and a need to consider how it can best be administered flexibly to increase uptake and personalization. We first discuss the core components of treatment for CBT through the lens of the Coping Cat treatment. Next, we review the empirical findings regarding adjustments made for CBT for youth anxiety delivered (a) in schools, (b) in community settings, (c) through telehealth, (d) through online computer programs, and (e) by caregivers at home. In each setting, we provide specific suggestions for how to implement CBT with flexibility while maintaining fidelity.

CBT for Youth Anxiety: How Does It Fit Within Community Mental Health?

PURPOSE OF REVIEW

We review (1) the empirical literature for cognitive behavioral therapy (CBT) for youth anxiety delivered in community settings, (2) the use of online delivery methods in this process, and (3) identified barriers and facilitators to implementation of CBT for youth anxiety in community mental health clinics (CMHCs). We provide suggestions for future work.

RECENT FINDINGS

Meta-analytic reviews of effectiveness studies suggest that outcomes comparable to those of efficacy studies can be achieved in community settings, particularly when in-session exposures occur. Several online programs support delivery of these services, with an evidence base that is promising. The notable barrier to the implementation of services is the cost of implementation and sustainability. Organizational factors such as leadership, culture, and climate are consistently identified as barriers and facilitators depending on their valence and appear to be related to implementation outcomes (e.g., on provider attitudes). The current findings need to be integrated into future studies, with a focus on further identifying facilitators (e.g., champions and online programs) of implementation. There is also the need for efforts to address organizational and individual barriers and to compare ways to reduce costs.

Individual and organizational factors as predictors of early evidence-based practice adoption in Michigan high schools: Baseline data from an implementation trial

Background

Adolescents increasingly access mental health services in schools. School mental health professionals (SPs; school counselors, social workers, etc.) can offer evidence-based mental health practices (EBPs) in schools, which may address access gaps and improve clinical outcomes. Although some studies have assessed factors associated with EBP adoption in schools, additional research focusing on SP- and school-level factors is warranted to support EBP implementation as SPs' mental health delivery grows.

Methods

Baseline data were collected from SPs at Michigan high schools participating in a statewide trial to implement SP-delivered cognitive behavioral therapy (CBT) to students. Models examined factors associated with attitudes about EBPs, implementation climate, and implementation leadership, and their associations with CBT knowledge, training attendance, and pre-training CBT delivery.

Results

One hundred ninety-eight SPs at 107 schools (87%) completed a baseline survey. The mean Evidence-Based Practice Attitude Scale (EBPAS) total score was 2.9, and school-aggregated mean scores of the Implementation Climate Scale (ICS) and Implementation Leadership Scale (ILS) were 1.83 and 1.77, respectively, all on a scale ranging from 0 (low) to 4 (high). ICS and ILS scores were lower than typically reported in clinical settings, while EBPAS scores were higher. School characteristics were not significantly associated with EBPAS, ICS, or ILS scores, but scores did differ by SP role. Higher EBPAS scores were associated with more CBT knowledge (average marginal effect for 1 SD change [AME] = 0.15 points) and a higher probability of training completion (AME = 8 percentage points). Higher ICS scores were associated with a higher probability of pre-training CBT delivery (AME = 6 percentage points), and higher ILS scores were associated with higher probability of training completion (AME = 10 percentage points).

Conclusions

Our findings suggest that SPs' attitudes toward EBPs and organizational support were positively associated with early signs of implementation success. As schools increasingly fill the adolescent mental healthcare access gap, efforts to strengthen both provider attitudes toward EBP and strategic organizational factors supporting EBP delivery will be key to encouraging EBP uptake in schools.

Plain Language Summary

Schools are an important setting in which adolescents receive mental healthcare. We need to better understand how to implement evidence-based practices (EBPs) in this setting to improve student mental health. This study examined the attitudes and perceptions of school professionals (SPs) as key contributors to the implementation of a particular EBP, the delivery of cognitive behavioral therapy (CBT) in schools. The study found that implementation climate and leadership scores in participating schools were lower than scores typically reported in clinical settings, while scores for SP attitudes about EBP adoption were higher than typical scores in clinical settings. Results further suggest that SPs with more positive attitudes toward EBPs are more knowledgeable of CBT and more likely to complete a 1-day CBT training. We also found that higher implementation climate scores were associated with SPs reporting pre-training CBT delivery (although this association was not statistically significant), and more implementation leadership was associated with SPs completing the CBT training. These findings suggest that SP attitudes toward EBPs and organizational support in schools are positively associated with early signs of implementation success. Early, low-intensity efforts to (1) improve SP attitudes about mental health EBPs, and (2) increase schools' support for implementation may scaffold more intensive implementation efforts in schools down the road.

Variation in Stakeholder Preferences for Implementing Evidence-Based Practices in Behavioral Health Care

Objective

The authors examined whether stakeholders in behavioral health care differ in their preferences for strategies that support the implementation of evidence-based practices (EBPs).

Methods

Using data collected in March and April 2019 in a survey of stakeholders in Philadelphia Medicaid’s behavioral health care system, the authors compared empirical Bayes preference weights for implementation strategies across clinicians, supervisors, agency executives, and payers.

Results

Preferences for implementation strategies overlapped among the stakeholders (N=357 survey respondents). Financial incentives were consistently ranked as most useful and performance feedback as the least useful for implementing EBPs. However, areas of divergence were identified. For example, payers preferred compensation for EBP delivery, whereas clinicians considered compensation for time spent on preparing for EBPs as equally useful.

Conclusions

The observed variation in stakeholder preferences for strategies to implement EBPs may shed light on why the ongoing shift from volume to value in behavioral health care has had mixed results.

A Mixed-Method Study Examining Solutions to Common Barriers to Teachers' Adoption of Evidence-Based Classroom Practices

Objectives

We conducted a mixed-method focus group study to (a) assess the appropriateness and likely effectiveness of strategies that target individual behavior change mechanisms associated with perceived barriers of lack of time and unsupportive leadership and (b) identify recommendations regarding strategies for overcoming the barriers.

Method

Sample included 39 school-based staff (80% female, 77% White) across two districts in the Midwest. Mixed methods included a simultaneous approach.

Results

Lack of time and supportive leadership continue to pervade school-based implementation efforts. Recommendations centered around the need for school leaders to give teachers the power to re-prioritize how they spend their time as well as providing protected, facilitated time for teachers to collaborate and learn practical skills targeting self-advocacy.

Conclusion

Our findings provide compelling evidence for the use of implementation methodology to strategically target mechanisms of individual behavior change during the process of incorporating new and innovative practices in schools.

Developing a statewide network of coaches to support youth access to evidence-based practices

Background: A national shortage of mental health providers for youth exists in the United States. Implementation support for mental health services in schools, where students are most likely to access care, can help to fill these gaps. Coaching consists of in vivo modeling and support during service delivery and is effective in supporting the implementation of evidence-based practices (EBPs). This implementation report describes the recruitment and training of community providers to become coaches as a part of a modified train-the-trainer model of implementation support. Method: An EBP implementation program, Transforming Research into Action to Improve the Lives of Students (TRAILS), trained community providers in Michigan to increase knowledge of cognitive behavioral therapy (CBT) and position them as coaches in schools. The development of the coach network involved five stages prior to the initiation of a randomized controlled trial: (1) recruitment, (2) a one-day clinical training, (3) 12 weeks of individualized consultation, (4) evaluation, and (5) training in the coaching protocol. Results: A total of 347 individuals attended an initial training, and 187 were paired with a consultant. Eighty-six clinicians from 47 of Michigan's 83 counties successfully became coaches by completing all required elements of training. Coaches showed significant improvements in the use and knowledge of CBT across consultation. Conclusion: Statewide networks of trained mental health professionals can address gaps in mental healthcare for youth. This article demonstrates one strategy for strengthening and leveraging community expertise to support the implementation of EPBs in schools.

Plain Language Summary

Although youth face many barriers in accessing effective mental health care, schools are one setting where they can more easily receive treatment. Research shows that training and supports are needed for school mental health professionals to provide effective care. Coaching, which involves in vivo support for school mental health professionals, is one helpful strategy. We describe the process of recruiting and training community clinicians to become coaches. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program successfully recruited and trained a network of 86 community clinicians to become coaches. Clinicians attended two day-long trainings and participated in 12 weeks of personalized consultation. Clients to whom these clinicians provided CBT showed significant symptom improvement. Clinicians also reported that they increased their knowledge and use of core CBT strategies, including psychoeducation, exposure, and behavioral activation. Community mental health professionals who are trained as coaches can address gaps in access to care for youth. We demonstrate one strategy for strengthening and leveraging clinicians’ knowledge of CBT to support the school-based implementation of CBT.

Mental health clinician perspectives regarding factors impacting implementation of evidence-based psychotherapies in Veterans Health Administration community-based outpatient clinics

OBJECTIVE

Uptake of Evidence-Based Psychotherapies (EBPs) by mental health (MH) clinicians, especially in community settings, remains highly variable. This formative pilot study aimed to understand the attitudes and practices of Veterans Health Administration community-based MH clinicians regarding EBPs and to identify multi-level factors that enable and hinder EBP implementation in this unique context.

METHODS

Semi-structured interviews were conducted with MH clinicians (N = 40) working in community-based outpatient clinics (CBOCs) in metro/urban (n = 20) and non-metro/rural (n = 20) locations. Interviews were guided by the Consolidated Framework for Implementation Research and were analyzed using rapid content analysis. Results were organized by system-, clinician-, patient-, and innovation-levels.

RESULTS

EBPs were consistently perceived as important to delivering quality MH care, with most clinicians having received training in at least one VHA EBP. However, limited EBP training and consultation opportunities, inadequate autonomy to schedule EBP sessions, high and complex caseloads, and feelings of isolation at CBOCs decreased EPB use. Social workers perceived disparities in EBP training access relative to psychologists. Some barriers were more salient in non-metro/rural settings (e.g., patient-level privacy concerns).

CONCLUSIONS

Increased EBP training opportunities- particularly for social workers-, greater flexibility over schedules and caseloads, and more mechanisms for consultation and professional development may increase EBP uptake in community-based clinics.

Implementation of the Wolverine Mental Health Program, Part 1: Adoption Phase

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS's readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.

Expanding the reach of evidence-based mental health interventions to private practice: Qualitative assessment using a policy ecology framework

Background

Evidence-based interventions (EBIs) for mental health disorders are underutilized in routine clinical practice. Exposure therapy for anxiety disorders is one particularly difficult-to-implement EBI that has robust empirical support. Previous research has examined EBI implementation determinants in publicly funded mental health settings, but few studies have examined EBI implementation determinants in private practice settings. Private practice clinicians likely face unique barriers to implementation, including setting-specific contextual barriers to EBI use. The policy ecology framework considers broad systemic determinants, including organizational, regulatory, social, and political contexts, which are likely relevant to EBI implementation in private practice settings but have not been examined in prior research.

Methods

Qualitative interviews were conducted to assess private practice clinicians' perceptions of EBI implementation determinants using the policy ecology framework. Clinicians were asked about implementing mental health EBIs broadly and exposure therapy specifically. Mixed methods analyses compared responses from clinicians working in solo vs. group private practice and clinicians who reported high vs. low organizational support for exposure therapy.

Results

Responses highlight several barriers and facilitators to EBI implementation in private practice. Examples include determinants related to organizational support (e.g., colleagues using EBIs), payer restrictions (e.g., lack of reimbursement for longer sessions), fiscal incentives (e.g., payment for attending training), and consumer demand for EBIs. There were notable differences in barriers faced by clinicians who work in group private practices compared to those working in solo practices. Solo private practice clinicians described ways in which their practice setting limits their degree of colleague support (e.g., for consultation or exposure therapy planning), while also allowing for flexibility (e.g., in their schedules and practice location) that may not be available to clinicians in group practice.

Conclusions

Using the policy ecology framework provides a broad understanding of contextual factors that impact private practice clinicians' use of EBIs, including exposure therapy. Findings point to potential implementation strategies that may address barriers that are unique to clinicians working in private practice.

Improving Delivery Behaviors During Exposure for Pediatric OCD: A Multiple Baseline Training Trial With Community Therapists

This study tested whether a new training tool, the Exposure Guide (EG), improved in-session therapist behaviors (i.e., indicators of quality) that have been associated with youth outcomes in prior clinical trials of exposure therapy. Six therapists at a community mental health agency (CMHA) provided exposure therapy for 8 youth with obsessive-compulsive disorder (OCD). Using a nonconcurrent multiple baseline design with random assignment to baseline lengths of 6 to 16 weeks, therapists received gold-standard exposure therapy training with weekly consultation (baseline phase) followed by addition of EG training and feedback (intervention phase). The primary outcome was therapist behavior during in-session exposures, observed weekly using a validated coding system. Therapist behavior was evaluated in relation to a priori benchmarks derived from clinical trials. Additional outcomes included training feasibility/acceptability, therapist response to case vignettes and beliefs about exposure, and independent evaluator-rated clinical outcomes. Three therapists reached behavior benchmarks only during the EG (intervention) phase. Two therapists met benchmarks during the baseline phase; one of these subsequently moved away from benchmarks but met them again after starting the EG phase. Across all therapists, the percentage of weeks meeting benchmarks was significantly higher during the EG phase (86.4%) vs. the baseline phase (53.2%). Youth participants experienced significant improvement in OCD symptoms and global illness severity from pre- to posttreatment. Results provide initial evidence that adding the EG to gold-standard training can change in-session therapist behaviors in a CMHA setting.

Perception and barriers to the use of cognitive-behavioral therapy in the treatment of depression in primary healthcare centers and family medicine clinics in Saudi Arabia

BACKGROUND

General practitioners (GPs) and family medicine physicians (FMPs) have a vital role to play in co-ordinating the care for mental disorders. The objective of this study was to determine the perception of GPs and FMPs on the use of cognitive-behavioral therapy (CBT) for depression in Saudi Arabia, and the barriers against the implementation of CBT in such settings.

MATERIALS AND METHODS

All physicians working in Primary Healthcare Centers and Family Medicine Clinics in Saudi Arabia were targeted and invited to participate in this cross-sectional study. A self-administered online questionnaire was sent via E-mail through the Saudi Commission for Health Specialties and the Saudi Society of Family and Community Medicine. Data was collected using an existing validated questionnaire and was modified to fit the objectives of current study.

RESULTS

A total of 469 FMPs and GPs completed the survey; the mean age of respondents was 38 years. More than half of the FMPs' and GPs' (53%) showed a positive perception of the use of CBT in primary healthcare settings. Most participants (91.9%) were willing to use CBT if they had adequate education and training. More than half of the participants (59.5%) thought it was time-consuming, while 39% thought that CBT training was a very time-intensive process.

CONCLUSION

We conclude that more than half of the physicians clearly had a good perception of the effectiveness of CBT administration in primary healthcare settings. Younger physicians were more perceptive. The most agreed-on barrier to CBT implementation was the lack of training and education.

Clinical Supervision in Community Mental Health: Characterizing Supervision as Usual and Exploring Predictors of Supervision Content and Process

Clinical supervision can be leveraged to support implementation of evidence-based practices in community mental health settings, though it has been understudied. This study focuses on 32 supervisors at 23 mental health organizations in Philadelphia. We describe characteristics of supervisors and organizations and explore predictors of supervision content and process. Results highlight a low focus on evidence-based content and low use of active supervision processes. They underscore the need for further attention to the community mental health context when designing supervision-targeted implementation strategies. Future work should assess whether supervision models specific to community mental health are needed.

Bringing Evidence-Based Interventions into the Schools: An Examination of Organizational Factors and Implementation Outcomes

Although schools are one of the largest providers of behavioral health services for youth, many barriers exist to the implementation of evidence-based interventions in schools. This study used the Stages of Implementation Completion (SIC) to examine school-based implementation outcomes for a computer-assisted cognitive behavioral therapy intervention for anxious youth. Organizational factors and predictors of program startup also were examined. Results indicated that the SIC detected implementation variability in schools and suggested that spending more time completing pre-implementation activities may better prepare schools for active implementation of program delivery. Furthermore, proficiency emerged as a potentially important organizational factor to examine in future school-based implementation research.

Identifying the organizational innovation-specific capacity needed for exposure therapy

BACKGROUND

Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care.

METHODS

We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings.

RESULTS

In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations.

CONCLUSIONS

Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients' access to effective treatment for anxiety disorders.

Providers’ Experiences with Delivering School-Based Targeted Prevention for Adolescents with Anxiety Symptoms: A Qualitative Study

The school setting is important for delivering targeted prevention to adolescents with anxiety. However, schools may not have available providers with training or experience in delivering evidence-based interventions, e.g., school psychologists. Training providers available in the schools, e.g., school nurses, is important. Further, to investigate their experiences in delivering targeted prevention to adolescents with anxiety could help understand factors promoting implementation success. A qualitative study including focus groups with providers of school-based targeted prevention cognitive-behavioral therapy for anxiety in adolescents was conducted. Focus group interviews were audiotaped and transcribed verbatim. Systematic Text Condensation, a method for thematic cross-case analysis was used. The Active Implementation Framework (AIF) was used to contextualize the results. Seventeen providers participated in the study. They reported several facilitators contributing to successful implementation: Their feeling of competence in delivering the interventions were built through skills-based training, supervision, and collegial support. Conducting initial assessment of each adolescent helped the providers individualize the interventions. Seeing positive outcomes in adolescents gave the providers motivation to continue implementation. Further, collaborating with teachers facilitated both recruitment of adolescents and administering group sessions. Minimal leadership-oriented factors were reported. Overall, the findings correspond to some of the drivers in AIF. This study offers providers’ perspectives on implementation of targeted prevention for anxiety in the school setting. Our results show that providers experience mastery in delivery when receiving support, training, and supervision. This seems to be essential facilitators for implementing much needed targeted prevention for youth with anxiety.

Brief, Non-Pharmacological, Interventions for Pediatric Anxiety: Meta-Analysis and Evidence Base Status

In 1998, Ost published [One-session treatment of specific phobias-a rapid and effective method] [in Swedish] giving rise to the idea that brief, intensive, and concentrated psychosocial interventions could exhibit public health impact. At this juncture, and per criteria of the Society for Clinical Child and Adolescent Psychology, there are data supporting that brief, non-pharmacological intervention [prescriptions] for pediatric anxiety can be considered well-established or probably efficacious. In addition, data from 76 randomized controlled trials (N = 17,203 youth) yield an overall mean effect size of 0.19 on pediatric anxiety outcomes (pre-post). Note, however, that effect sizes vary significantly. These data point to the capacity for clinical change coming from in-vivo exposures for specific phobias (~3 h, one session), CBT with social skills training (~3 h, six sessions for indicated prevention and early intervention), and CBT-based parent training (~6 h, eight digital modules with clinician support). Given such evidence, we recommend efforts be made to establish ways to position such treatment innovations for rapid deployment facilitated by high-quality training, monitoring, technical assistance, and ongoing disclosures.

Therapists' characteristics associated with the (non-)use of exposure in the treatment of anxiety disorders in youth: A survey among Dutch-speaking mental health practitioners

INTRODUCTION

Although there is consensus that exposure is the key ingredient in treating childhood anxiety disorders, several studies in the USA suggest exposure to be underused in clinical practice. Previous research pointed to therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety as important factors in the underusage of exposure in the treatment of adult anxiety disorders. This study examined what therapist characteristics may be involved in the (non-)use of exposure in treating childhood anxiety disorders.

METHODS

An internet-based survey among 207 youth mental health care professionals in the Netherlands and Belgium was conducted to assess therapists' beliefs about exposure, their age, experience, caseload, training and theoretical orientation, as well as the level of the therapists' own anxiety, depression and stress.

RESULTS

The current survey showed that therapists used exposure in about half of their cases of childhood anxiety and that the non-use was independently associated with the relatively strong negative beliefs about exposure, therapists' age, and non-CBT orientation.

DISCUSSION

Findings point to the importance of addressing negative beliefs about exposure in therapists' training and supervision to resolve therapy drift away from exposure, and consequently improve utilization and delivery of exposure-based therapy for childhood anxiety disorders.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study

Background

Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account.

Objective

The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context.

Methods

Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis.

Results

Therapists used the protocol as a “toolbox” comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components.

Conclusions

A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Barriers to Implementing a Group Treatment for Maternal Depression in Head Start: Comparing Staff Perspectives

Although providing depression treatment for Head Start mothers may improve child wellbeing, interventions have not been widely used for this purpose. This failure may be due to the characteristics of clients, interventions, or the systems of care in which services are delivered. This study explored barriers to implementing Interpersonal Psychotherapy-Group with ethnic minority Head Start mothers, including differences in the level of staff consensus regarding barriers, which may predict implementation success. Barriers included resource challenges, cultural and linguistic differences, and participant concerns, and staff demonstrated low to moderate consensus. Results emphasize the importance of engaging diverse stakeholders in implementation.

Outcomes Associated With Adapting a Research-Supported Treatment for Children With Behavior Disorders

PURPOSE

The aims of this study are to describe an adaptation process of a research-supported treatment (RST) for children with oppositional defiant disorder and to examine provider attitudes toward RSTs prior to and following this process.

METHOD

Providers from 14 agencies in New York State delivered the adapted RST, following training. Attitudes toward RSTs were measured by the Evidence-Based Practice Attitude Scale at baseline and posttest.

RESULTS

Openness toward RSTs decreased from baseline to posttest. The majority of providers reported modifications to the structure and process of the intervention.

DISCUSSION

To improve the uptake and usability of RSTs in practice, future research must further address adaptation processes and their relationships to attitudes toward RSTs.

Therapists' Perceptions of Individual Patient Characteristics that May Be Hindering to Group CBT for Anxiety and Depression

Objective: Individual patient characteristics are important in trying to understand why people respond differently to group CBT. Only a few studies have explored therapists' perceptions of within-patient attributes that may be hindering in group CBT in a mental health setting. Method: We explored the perception of individual patient characteristics and related obstacles in 12 psychotherapists in Danish Mental Health Services through semi-structured interviews. The interviews were analyzed using a descriptive qualitative framework. Results: The results revealed four distinct themes that the therapists pointed to as important for the outcome of a 14-week group CBT intervention for social phobia, panic disorder, agoraphobia and major depressive disorder. The four themes were Complexity & severity, External circumstances, Attitudes & coping and Cognitive ability & reflection level. The therapists explained how they perceived higher complexity and severity in the patients as an obstacle, they highlighted that a calm and stable outside environment aided therapeutic change, whilst stressors were hindering. They perceived active coping mechanisms, positive attitudes and high readiness to change as positive factors, whilst dependent and hostile coping mechanisms and negative attitudes were seen as obstacles. Finally, the therapists pointed to cognitive abilities and reflection level, explaining how it could be difficult to obtain good outcomes for patients who's cognitive abilities were debilitated due to psychopathological factors or for patients with a generally low reflection level. Conclusions: The results indicated that the therapists experience group CBT as an intervention that requires certain prerequisites of the patients, and that the four themes should be considered when deciding on treatment options for any given patient. The clinical utility and theoretical implications of the results are discussed.

Glutamate Systems in DSM-5 Anxiety Disorders: Their Role and a Review of Glutamate and GABA Psychopharmacology

Serotonin reuptake inhibitors and benzodiazepines are evidence-based pharmacological treatments for Anxiety Disorders targeting serotonin and GABAergic systems, respectively. Although clearly effective, these medications fail to improve anxiety symptoms in a significant proportion of patients. New insights into the glutamate system have directed attention toward drugs that modulate glutamate as potential alternative treatments for anxiety disorders. Here we summarize the current understanding of the potential role of glutamate neurotransmission in anxiety disorders and highlight specific glutamate receptors that are potential targets for novel anxiety disorder treatments. We also review clinical trials of medications targeting the glutamate system in DSM-5 anxiety disorders. Understanding the role of the glutamate system in the pathophysiology of anxiety disorder may aid in developing novel pharmacological agents that are effective in treating anxiety disorders.

The ReThink study: a 3-arm parallel randomized trial of cognitive bias modification, with and without adherence promotion, for adolescent anxiety disorder: trial design and protocol

BACKGROUND

Anxiety disorders are the most common mental health problem among youth, contribute to reduced quality of daily life, and are associated with high rates of comorbidity. However, treatment rates for anxiety are very low, causing a sizeable treatment gap. There is an immediate need to identify treatment interventions that are effective, affordable, and can be delivered easily to the youth population. Cognitive Bias Modification (CBM) is one potentially effective intervention that could reach youth on a large scale, especially when self-administered at home. Thus, we aim to assess the benefit of CBM to treat youth anxiety. Further, we aim to test whether adding an adherence promotion (AP) component to the CBM intervention can improve outcomes, and whether CBM delivered both with and without the AP component is cost effective.

METHODS

This is a 12-month randomized controlled trial (RCT) conducted within an existing healthcare system. Potentially eligible youth (ages 12 to 17) will be identified by reviewing the electronic health record (EHR) for clinical anxiety diagnoses, which are then confirmed via research interview. We aim to enroll 498 participants and randomize them 1:1:1 to one of three arms: Arm 1 is a Low-Ratio version of the CBM program (nearly identical to the other CBM versions, but minimally effective); Arm 2 is a High-Ratio "active" CBM program; and Arm 3 is the High-Ratio CBM program with an added AP component. Participants will complete assessments at baseline, 1-, 3-, 6- and 12-months post-baseline. Youth in all three arms will self-administer the CBM program at home and will be asked to complete twelve intervention sessions over a four-week period. Arm 3 participants (High-Ratio CBM + AP) will also receive up to four telephone calls from phone coaches during the intervention period to provide technical assistance, encouragement, and motivational enhancement to increase adherence. The primary clinical outcome will be anxiety remission at 6-month follow-up.

DISCUSSION

This study protocol describes the method and design for an RCT to test whether self-administered CBM both with and without adherence promotion can be an effective at-home treatment for anxious youth.

TRIAL REGISTRATION

ClinicalTrials.gov : NCT02156531, First Posted June 5, 2014.

Factors associated with young people's attendance at an IPV prevention intervention in informal settlements in South Africa: A prospective analysis

Understanding factors shaping attendance at behavioural interventions is critical for programmatic planning. Through the Stepping Stones and Creating Futures intervention trial amongst young (18-30) women and men to reduce intimate partner violence and strengthen livelihoods, we prospectively assessed factors associated with intervention attendance. Baseline data were collected between September 2015 and September 2016 among 677 women and 675 men. For women, in multinomial models, compared to high attenders, medium (β = -0.04, p = 0.001) and low (β = -0.05, p = 0.003) attenders had lived less time in the community, medium attenders were more likely to have children (β = 0.97, p = 0.001), and low attenders had less gender-equitable attitudes (β = -0.57, p = 0.035). For men, in multinomial models, compared to high attenders, medium attenders were more likely to have completed secondary school (β = 1.48, p = 0.011) and to have worked in the past three months (β = 0.64, p = 0.021). Low attenders had lived for a shorter period in the community (β = -0.06, p = 0.005), and were more likely to have worked in the past three months (β = 0.66, p = 0.041) compared to high attenders. Attendance was shaped by structural factors, and gender-specific factors, and these need to be incorporated into future interventions.

After the Study Ends: A Qualitative Study of Factors Influencing Intervention Sustainability

Sustaining evidence-based practices after initial training and support has ended is necessary to ensure lasting improvements in youth mental health services. This study examined factors impacting community clinicians' decisions to sustain a transdiagnostic youth intervention following participation in a study. The aim of the study was to identify potentially mutable factors impacting sustainability to inform future implementation efforts. Thirteen clinicians (85% women, 92% Caucasian, M age = 35.6) completed interviews after participating in an open trial of an evidence-based intervention for depression, anxiety, and conduct disorders. Interviews were analyzed using thematic analysis methods. All (100%) clinicians reported current use of the intervention. Four themes emerged related to sustainability. Clinicians (100%) reported that making modifications, alignment with prior training, and relative advantage influenced their current intervention use. Clinicians (100%) reported that knowledge transfer from treatment developers was vital to sustainability. They (92%) noted a number of logistical, inner-organizational, and client-level barriers to sustainability. Lastly, clinicians (92%) identified factors related to scaling up the intervention. A variety of personal, organizational, logistical, and client variables influence the sustainment of new interventions, and could be leveraged in future implementation efforts.

Individualized Progress Measures Are More Acceptable to Clinicians Than Standardized Measures: Results of a National Survey

Despite research supporting measurement-based care grounded in standardized progress measures, such measures are underutilized by clinicians. Individualized measures of client-specific targets present an alternative, but little is known about their acceptability or use. We compared attitudes toward and use of standardized and individualized progress measures in a national sample of 504 clinicians. Clinicians reported neutral to positive attitudes toward both types of measures, but strongly preferred and were more likely to use individualized measures. Clinician attitudes, theoretical orientation, and work setting predicted assessment preferences and practices. Implications for dissemination and implementation of measurement-based care are discussed.

What is important for the sustained implementation of evidence-based brief psychotherapy interventions in psychiatric care? A quantitative evaluation of a real-world programme

PURPOSE

Behavioural activation and motivational interviewing, both evidence-based treatments (EBTs), were implemented in secondary psychiatric care. This longitudinal evaluation of a real-world programme focused on the penetration of EBT adoption and its associations with therapist-related and perceived intervention-related variables. The implementation plan was also compared to sub-processes of Normalization Process Theory.

MATERIAL AND METHODS

Six participating units employed 72 therapists regularly and they comprise the target group. Due to staff turnover, a total of 84 therapists were trained stepwise. Three survey points (q1, q2, q3) were set for a four-year cycle beginning a year after the initial training and completed 4-5 months after closing patient recruitment. The implementation plan included two workshop days, one for each EBT, and subsequent case consultation groups and other more general strategies.

RESULTS

Fifty-seven (68%) of programme-trained therapists responded to one or more of three questionnaires. The self-reported penetration covers about a third of the target group a few months after the completion of the programme. Therapists' favourable perceptions of the EBTs regarding relative advantage, compatibility and complexity were associated with their sustained adoption. Therapists' background factors (e.g. work experience) and positive adoption intention at q1 did not predict the actual adoption of the EBTs at q3. No specific sustainment strategies were included in the implementation plan.

CONCLUSION

Brief but multi-faceted training with subsequent case consultations promoted the adoption of EBTs in a real-world setting. Adding specific sustainment strategies to the implementation plan is proposed to ensure the long-term survival of the implementation outcomes.

Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings

BACKGROUND

The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families.

OBJECTIVE

The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists' self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children's mental health services.

METHOD

One hundred and three therapists reported on two types of engagement challenges-Limited Client Engagement and Expressed Client Concerns-in 702 sessions with 274 clients.

RESULTS

Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. Both types of engagement challenges were negatively associated with therapists' report of their ability to carry out intended activities in the same session.

CONCLUSIONS

Findings suggest that therapists may benefit from learning strategies to address these two distinct types of engagement challenges encountered in implementation of EBPs with diverse families in community settings.

Patterns and predictors of compliance with utilization management guidelines supporting a state policy to improve the quality of youth mental health services

Despite a need to improve community mental health services for youths, little is known about compliance with state policies created to improve the quality of services in these settings. This study examined rates, patterns, and predictors of compliance with utilization management guidelines developed by the state of Texas to support a public health policy based on empirical evidence of effective mental health services (i.e., an evidence-based policy). Compliance was defined as authorizing policy-recommended service packages, whereas policy "overrides" occurred when recommended service packages were not authorized. The study sample consisted of 688 youths from ethnically and economically diverse backgrounds. Clinics reported that forty-six percent of youths were not authorized the policy-recommended service package. Overrides were primarily based on level of intensity. Most often, authorized services were less intensive than those recommended by the state guidelines. Higher severity at intake across multiple indicators was associated with authorizing less intensive services than what the policy guidelines recommended. Future studies evaluating system-level efforts such as state mental health policies should pay close attention to levels of service intensity, and their relation to the needs of youth in community settings.