Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA

Measurement-Based Care as a Tool to Detect and Prevent Harm in Youth Psychotherapy

Measurement-based care (MBC), the use of routine assessment to guide clinical decision-making, has the potential to significantly enhance the quality of mental health services for youth by improving the detection and prevention of harm. Concerns exist, however, that widespread efforts to implement MBC may have a negative impact on youth mental health care. We explore both perspectives by describing how MBC can be leveraged as a tool to detect and prevent harmful treatment in youth and how misapplication of MBC also has the potential to cause harm. This discussion focuses on how MBC can help therapists identify harm caused by ineffective practices (i.e., deterioration or no symptoms changes), poor client engagement (e.g., early drop-out, poor alliance), and adverse events (e.g., injury caused by treatment). We also discuss multi-level applications of aggregated MBC data to prevent harm through workforce development and organizational and health systems quality and cost of care improvement initiatives. Misapplication of MBC by failing to adhere to MBC best practices, overreliance on data above clinical judgement, providing insufficient organizational support, and using MBC data to justify cost containment are all discussed as possible sources of harm. We conclude with a discussion of future directions for research needed to advance the application of MBC to the prevention of harm in youth psychotherapy.

To evaluate the EASE intervention for reducing anxiety and depression among adolescents in Pakistan: a protocol for a mixed methods study, including a cluster-randomised controlled trial

INTRODUCTION

The rising prevalence of adolescent anxiety and depression in low- and middle-income countries (LMICs) highlights the urgency for effective interventions. Challenges with standard treatments necessitate exploring accessible strategies. In addition, adapting interventions from high-income countries to LMICs raises concerns about efficiency. The LMIC-tailored Early Adolescent Skills for Emotions (EASE) intervention, integrating cognitive-behavioural principles, group sessions, non-specialist delivery and parental involvement, provides a promising solution. This protocol aims to evaluate the effectiveness, acceptability and feasibility of the intervention in public schools in Multan, Pakistan, for addressing anxiety and depression among adolescents.

METHOD AND ANALYSIS

This proposed study aims to achieve its objectives through a two-phase approach by using a mixed methods experimental design. Primarily, a cluster randomised control trial with a two-arm (intervention and waitlist control) single-blinded design will assess the effectiveness of the EASE intervention in reducing anxiety and depression (primary outcome) and parenting, quality of life and psychological distress (secondary outcome) among adolescents aged 13-19, employing a 1:1 allocation ratio. Subsequently, leveraging effectiveness data, the study will explore moderating (eg, socioeconomic characteristics) and mediating pathways (parenting skills and parents' psychological distress) to enhance our comprehension of the intervention's effectiveness. Lastly, an exploratory descriptive qualitative study will investigate the perceptions of various stakeholders regarding the acceptability and feasibility of the School-Based Mental Health Programme intervention in the Pakistani context. For the trial data, linear mixed models will be used to account for clustering at the school level and adjust for baseline differences. For the qualitative data, content analysis will be conducted to identify stakeholder perceptions about the intervention.

ETHICS AND DISSEMINATION

The study received ethical approval from the Ethics Committee of the School of Nursing and Rehabilitation at Shandong University, Jinan, China (Reference No. 2023-R-024) and Institutional Review Board (Ref: IRB-2019/MASH/Approval-06/March/2023) Mukhtar A Sheikh Hospital, Multan. The findings will be shared through publications in peer-reviewed journals and presentations at national and international conferences.

TRIAL REGISTRATION NUMBER

This trial is registered at ClinicalTrials.gov (ID NCT06155838).

Effective School Leadership for Supporting Students' Mental Health: Findings from a Narrative Literature Review

There is a compelling literature base in the field of education that highlights how school leaders are crucial to improving academic processes and outcomes, including instruction and raising student achievement. Research has also demonstrated that effective school leaders exhibit behaviors aligned with promoting the core issues of teaching, learning, and school improvement. Less well-known is what science says about the effectiveness of professional development and leadership preparation programs for developing the competencies needed for addressing the diverse mental health needs of students. Better understanding the science is important as school leaders are increasingly tasked with connecting leadership behaviors to students' social and emotional outcomes, and these leaders play a large role in whether, and to what extent, mental health promotion and prevention are effectively implemented in school settings. Drawing from diverse literature bases of education and psychology, the primary objective of this narrative literature review is to determine and define effective leadership behaviors, skills, and competencies in the context of implementing school mental health programs and strategies. The secondary objective is to summarize the existing research examining leadership preparation and professional development programs that promote effective leadership practices and highlight examples of leadership programs focused on enhancing school mental health.

Measurement-Based Care in a Remote Intensive Outpatient Program: Pilot Implementation Initiative

BACKGROUND

The ongoing mental health crisis, especially among youth, has led to a greater demand for intensive treatment at the intermediate level, such as intensive outpatient programs (IOPs). Defining best practices in remote IOPs more broadly is critical to understanding the impact of these offerings for individuals with high-acuity mental health service needs in the outpatient setting. Measurement-based care (MBC), or the routine and systematic collection of patient-reported data throughout the course of care to make meaningful changes to treatment, is one such practice that has been shown to improve patient outcomes in mental health treatment. Despite the literature linking MBC to beneficial clinical outcomes, the adoption of MBC in clinical practice has been slow and inconsistent, and more research is needed around MBC in youth-serving settings.

OBJECTIVE

The aim of this paper is to help bridge these gaps, illustrating the implementation of MBC within an organization that provides remote-first, youth-oriented IOP for individuals with high-acuity psychiatric needs.

METHODS

A series of 2 quality improvement pilot studies were conducted with select clinicians and their clients at Charlie Health, a remote IOP program that treats high-acuity teenagers and young adults who present with a range of mental health disorders. Both studies were carefully designed, including thorough preparation and planning, clinician training, feedback collection, and data analysis. Using process evaluation data, MBC deployment was repeatedly refined to enhance the clinical workflow and clinician experience.

RESULTS

The survey completion rate was 80.08% (3216/4016) and 86.01% (4218/4904) for study 1 and study 2, respectively. Quantitative clinician feedback showed marked improvement from study 1 to study 2. Rates of successful treatment completion were 22% and 29% higher for MBC pilot clients in study 1 and study 2, respectively. Depression, anxiety, and psychological well-being symptom reduction were statistically significantly greater for MBC pilot clients (P<.05).

CONCLUSIONS

Our findings support the feasibility and clinician acceptability of a rigorous MBC process in a real-world, youth-serving, remote-first, intermediate care setting. High survey completion data across both studies and improved clinician feedback over time suggest strong clinician buy-in. Client outcomes data suggest MBC is positively correlated with increased treatment completion and symptom reduction. This paper provides practical guidance for MBC implementation in IOPs and can extend to other mental health care settings.

Reframing family-school partnerships to disrupt disenfranchisement of Black families and promote reciprocity in collaboration

Research has long demonstrated the benefits of family-school partnerships. However, these benefits often fail to generalize to all families, especially Black families. A present and historical pattern of discrimination and exclusion has contributed to the lack of benefits yielded from Black family-school partnerships. A major contributing factor is the narrow way in which schools define family engagement. Such narrow definitions often marginalize families from non-dominant backgrounds, particularly Black families, and reinforce harmful narratives that Black parents and families are uninvolved in their children's education. The combination of continued discrimination and exclusion as well as harmful narratives has impacted Black family-school partnering. However, schools can work to repair harm and rebuild partnerships with Black families. In this article, we advance a framework for such work. After grounding the need for this framework in a historical context, we emphasize three essential components to forming equitable Black family-school partnerships: (a) grounding relationship building in social justice, (b) integrating reciprocity in family-school relationships, and (c) usage of multiple and non-dominant methods and modalities to build relationships.

Provider Use of, Attitudes Towards, and Self-efficacy with Key Measurement-based Care Practices in Youth Mental Health Treatment: A Multi-site Examination

Measurement-based care (MBC) is an underutilized evidence-based practice, and current implementation efforts demonstrate limited success in increasing MBC use. A better understanding of MBC implementation determinants is needed to improve these efforts, particularly from studies examining the full range of MBC practices and that span multiple samples of diverse providers using different MBC systems. This study addressed these limitations by conducting a multi-site survey examining MBC predictors and use in youth treatment. Participants were 159 clinicians and care coordinators working in youth mental health care settings across the United States. Participants were drawn from three program evaluations of MBC implementation. Providers completed measures assessing use of five MBC practices (administering measures, viewing feedback, reviewing feedback in supervision, sharing feedback with clients in session, and using feedback to plan treatment), MBC self-efficacy, and MBC attitudes. Despite expectations that MBC should be standard care for all clients, providers reported only administering measures to 40-60% of clients on average, with practices related to the use of feedback falling in the 1-39% range. Higher MBC self-efficacy and more positive views of MBC practicality predicted higher MBC use, although other attitude measures were not significant predictors. Effects of predictors were not moderated by site, suggesting consistent predictors across implementation settings. Implications of study findings for future research and for the implementation of MBC are discussed.

Propelling the Global Advancement of School Mental Health

Rates of mental health problems and disorders in children and youth have been increasing for at least three decades, and these have escalated due to the pandemic and multiple other societal stressors. It is increasingly recognized that students and families frequently struggle to receive needed care through traditional locations such as specialty mental health centers. Upstream mental health promotion and prevention strategies are gaining support as a public health approach to supporting overall population well-being, better utilizing a limited specialty workforce, and reducing illness. Based on these recognitions, there has been a progressive and escalating movement toward the delivery of mental health support to children and youth "where they are," with a prominent and more ecologically valid environment being schools. This paper will provide a brief review of the escalating mental health needs of children and youth, advantages of school mental health (SMH) programs in better meeting these needs, example model SMH programs from the United States and Canada, and national and international SMH centers/networks. We conclude with strategies for further propelling the global advancement of the SMH field through interconnected practice, policy, and research.

Study protocol: Novel Methods for Implementing Measurement-Based Care with youth in Low-Resource Environments (NIMBLE)

BACKGROUND

For youth receiving care in community mental health centers, comorbidities are the rule rather than the exception. Using measurement-based care (MBC), or the routine evaluation of symptoms to inform care decisions, as the foundation of treatment for youth with comorbid problems significantly improves the impact of psychotherapy by focusing care and building engagement and alliance. MBC increases the rate of symptom improvement, detects clients who would otherwise deteriorate, and alerts clinicians to non-responders. Despite its demonstrated utility, MBC is rarely implemented with fidelity; less than 15% of providers report using MBC per recommendations. Previous efforts to support MBC implementation have yielded suboptimal outcomes, in part, due to organizations' challenges with identifying and prioritizing barriers and selecting and developing strategies to overcome them. New methods are needed for identifying and prioritizing barriers, and matching strategies to barriers to optimize MBC implementation and treatment quality to improve youth mental health outcomes in community settings.

METHODS

Pragmatic implementation methods will be piloted in four diverse community mental health centers. Methods include (a) rapid evidence synthesis; (b) rapid ethnography; (c) design kits (e.g., kits with disposable cameras, journals, maps); (d) barrier prioritization, and (e) causal pathway diagramming. These activities will generate actionable barriers; subsequently, we will use facilitated group processes to prioritize barriers and develop causal pathway diagrams to match strategies to barriers to create implementation plans that optimize MBC fidelity (Aim 1). We will track strategy deployment for 6 months, then compare MBC fidelity for another 6 months post-implementation with data from 2 years of historical controls (Aim 2). Finally, we will co-design a toolkit for design kit methods with youth and the practice and scientific communities (Aim 3).

DISCUSSION

Optimizing MBC implementation in community mental health centers could transform youth mental health care by ensuring the most pressing symptoms are targeted early in treatment. The discussion section highlights expected challenges and limits to using the five methods, including recruitment and engagement given the high pressure on community mental health settings.

TRIAL REGISTRATION

Clinicaltrials.gov. NCT05644756 . Registered on 18 November 2022. This trial was retrospectively registered.

Measurement feedback system implementation in public youth mental health treatment services: a mixed methods analysis

BACKGROUND

Prior studies indicate the effectiveness of measurement-based care (MBC), an evidence-based practice, in improving and accelerating positive outcomes for youth receiving behavioral health services. MBC is the routine collection and use of client-reported progress measures to inform shared decision-making and collaborative treatment adjustments and is a relatively feasible and scalable clinical practice, particularly well-suited for under-resourced community mental health settings. However, uptake of MBC remains low, so information on determinants related to MBC practice patterns is needed.

METHODS

Quantitative and qualitative data from N = 80 clinicians who implemented MBC using a measurement feedback system (MFS) were merged to understand and describe determinants of practice over three study phases. Quantitative, latent class analysis identified clinician groups based on participants' ratings of MFS acceptability, appropriateness, and feasibility and describes similarities/differences between classes in clinician-level characteristics (e.g., age; perceptions of implementation climate; reported MFS use; phase I). Qualitative analyses of clinicians' responses to open-ended questions about their MFS use and feedback about the MFS and implementation supports were conducted separately to understand multi-level barriers and facilitators to MFS implementation (phase II). Mixing occurred during interpretation, examining clinician experiences and opinions across groups to understand the needs of different classes of clinicians, describe class differences, and inform selection of implementation strategies in future research (phase III).

RESULTS

We identified two classes of clinicians: "Higher MFS" and "Lower MFS," and found similarities and differences in MFS use across groups. Compared to Lower MFS participants, clinicians in the Higher MFS group reported facilitators at a higher rate. Four determinants of practice were associated with the uptake of MBC and MFS in youth-serving community mental health settings for all clinicians: clarity, appropriateness, and feasibility of the MFS and its measures; clinician knowledge and skills; client preferences and behaviors; and incentives and resources (e.g., time; continuing educational support). Findings also highlighted the need for individual-level implementation strategies to target clinician needs, skills, and perceptions for future MBC and MFS implementation efforts.

CONCLUSION

This study has implications for the adoption of evidence-based practices, such as MBC, in the context of community-based mental health services for youth.