Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists

Brief psychological interventions for schizophrenia: a systematic review and meta-analysis

BACKGROUND

Although cognitive behavioral therapy for people diagnosed with schizophrenia (CBTp) is recommended in clinical guidelines internationally, rates of implementation are low. One consequence of this has been the development of brief individual psychological interventions, which are shorter than the recommended minimum of 16 sessions for CBTp. This article is the first to systematically identify the brief interventions that exist for people diagnosed with schizophrenia and to determine their effectiveness using meta-analysis.

METHODS

Five electronic databases (PsycINFO, MEDLINE, CINAHL, EMBASE, and Web of Science) were searched for peer-reviewed randomized controlled trials or experimental studies of brief individual psychological interventions delivered in community settings. Random effects meta-analysis was used to integrate effect sizes, due to the heterogeneity of included studies.

RESULTS

Fourteen studies were identified (n = 1,382) that measured thirty clinical outcomes and included six intervention types - brief CBT, memory training, digital motivation support, reasoning training, psychoeducation, and virtual reality. Collectively, brief psychological interventions were found to be effective for psychotic symptoms (SMD -0.285, p < 0.01), paranoia (SMD -0.277, p < 0.05), data gathering (SMD 0.38, p < 0.01), depression (SMD -0.906, p < 0.05) and wellbeing (SMD 0.405, p < 0.01). For intervention types, brief CBT was effective for psychotic symptoms (SMD -0.32, p < .001), and reasoning training was effective for data gathering (SMD 0.38, p < 0.01).

CONCLUSIONS

Overall, the evidence suggests that brief psychological interventions are effective for several key difficulties associated with schizophrenia, providing an opportunity to improve both access to, and choice of, treatment for individuals diagnosed with schizophrenia.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Knowledge of Problem Solving (KOPS) Scale: Design and Evaluation of a Digitally Administered Competence Measure for a Common Practice Element in Task-Shared Youth Mental Health Interventions

There are few reliable and feasible quality assurance methods to support scaling up of psychological interventions delivered by non-specialist providers. This paper reports on the phased development and validation of a digitally administered Knowledge of Problem Solving (KOPS) measure to assess competencies associated with a "task-shared" problem-solving intervention for adolescents with diverse mental health problems in India. Phase 1 established key competencies required to deliver the intervention, followed by item generation for a corresponding knowledge-based competency measure that could be administered efficiently through e-learning systems. In phase 2, items were refined based on responses from an "experienced" reference sample comprising 17 existing counsellors with direct experience of the problem-solving intervention, and a "novice" sample with 14 untrained university students and NGO staff. In phase 3, we evaluated two parallel versions of the measure in a validation sample (N = 277) drawn from universities and NGOs. The resulting 17-item measure was structured around a hypothetical case, followed by multiple-choice questions that asked about the most appropriate response to a practice-based scenario. The difficulty level of the test items was well matched to the ability level of participants (i.e. most items being of moderate difficulty and few items being easy or difficult). Only one item showed a negative discrimination index and was removed from the 17-item forms. The final 16-item version of the KOPS measure provides a scalable digital method to assess key psychotherapeutic competencies among non-specialists, particularly in relation to a transdiagnostic problem-solving intervention. Similar formats could be deployed more widely alongside e-learning programmes to expand the global workforce capable of delivering evidence-based psychological interventions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s41347-023-00356-9.

Evaluating an implementation model of evidence-based therapy for eating disorders in non-specialist regional mental health settings

BACKGROUND

Many people with eating disorders (EDs) either do not access treatment, access it well after symptoms first start, or drop out of treatment. This study evaluated ways to improve early access to evidence-based interventions for those with EDs in a non-specialist community setting.

METHODS

In an Australian regional community, links were formed between general medical practitioners and treatment providers (psychologists, mental health social workers and dietitians), who received ongoing training, feedback and support. Service users had access to 20-40 subsidised treatment sessions. Data were collected from 143 patients over 18 months. Our outcomes are reported according to the RE-AIM implementation framework: Reach (we measured uptake and treatment completion); Effectiveness (impact on disordered eating cognitions, body mass index, remission, and moderators of effectiveness including illness duration, previous treatment, presence of comorbidities, presence of a normative level of disordered eating, presence of any ED behaviours, weighing in treatment, multidisciplinary case conferencing, number of dietetic sessions); Adoption (drop-out and predictors); Implementation (barriers encountered); Maintenance (subsequent activity designed to embed new practices).

RESULTS

Treatment was completed by 71%; significant large decreases in eating disorder cognitions were achieved; remission was obtained by 37% (intent-to-treat). Treatment completion was predicted by lower baseline levels of disordered eating, uptake of ≥ 3 dietetic sessions, and ≥ 2 team case conferences. Greater improvement over time was predicted by regular case conferencing and in-session weighing.

CONCLUSIONS

Implementation of this model in a regional community setting produced completion rates and outcomes comparable to those found in specialist clinical trials of ED treatments. Service providers identified care coordination as the most important factor to connect users to services and help navigate barriers to ongoing treatment.

TRIAL REGISTRATION

This research was an invited evaluation of a project implemented by the Australian Department of Health. The project did not introduce any new clinical practice but sought to improve access to evidence-based multidisciplinary treatment for people with EDs by removing four known systemic barriers: securing an accurate diagnosis, availability of multidisciplinary treatment, cost of treatment, and intensity of treatment. As such, the project did not require trial registration. Notwithstanding, this evaluation obtained ethics approval (Bellberry Human Research Ethics Committee, Application No: 2018-09-728-FR-1).

Scale Up Task-Sharing of Psychological Therapies

(Reprinted from Lancet, Vol. 399, pp. 343-345, Copyright (c) 2021, with permission from Elsevier).

Fairburn C. EMPOWER: Toward the Global Dissemination of Psychosocial Interventions

Even before the COVID-19 pandemic, the needs for care of persons with mental illness remained largely unmet worldwide, testifying to the inadequacy of current approaches to mental health care and their unsuitability for the rising demand. One hurdle to improved access to quality care is the reliance on expensive specialist providers, particularly for the delivery of psychosocial interventions. This article describes EMPOWER, a not-for-profit program that builds on the clinical science demonstrating the effectiveness of brief psychosocial interventions for a range of psychiatric conditions; implementation science demonstrating the effectiveness of delivery of these interventions by non-specialist providers (NSPs); and pedagogical science demonstrating the effectiveness of digital approaches for training and quality assurance. The EMPOWER program leverages digital tools for training and supervising NSPs, designing competency-based curricula, assessing treatment-specific competencies, implementing measurement-based peer supervision for support and quality assurance, and evaluating impacts to enhance the effectiveness of the delivery system.

Effects of 1-day e-learning education on perinatal psychological support skills among midwives and perinatal healthcare workers in Japan: a randomised controlled study

BACKGROUND

Although midwives are expected to play a key role for psychological support throughout perinatal periods, their educational chances are limited. Versatile teaching strategies such as e-learning may be promising in expanding education. The objective of our study was to clarify the effects of an e-learning educational programme on midwives' empathic communication skills.

METHODS

From April 2019 to September 2019, a randomised controlled trial of a 1-day e-learning educational programme on perinatal psychological issues (both perinatal mental health assessment and empathic communication) was conducted to improve empathic communication skills of midwives and perinatal healthcare workers. Two types of measurements (paper-and-pencil multiple-choice test and video-viewing tests of simulated patient) were used to measure the competency of empathic communication skills.

RESULTS

Participants (N = 115) were randomly allocated to two groups (Intervention: n = 58, Control: n = 57). The intervention group was at a significantly higher level for both post-tests of empathic communication skills compared with the control group. Both intervention and control groups showed improvements in acquiring knowledge about perinatal mental health assessments.

CONCLUSIONS

The results of our study show that a 1-day e-learning programme helped improve the midwives' empathic communications skills. Therefore, an effective 1-day e-learning educational programme of perinatal mental health will expand opportunity to learn about empathic communication skills for midwives and perinatal healthcare workers.

TRIAL REGISTRATIONS

UMIN000036052.

Online training for evidence-based child trauma treatment: evaluation of the German language TF-CBT-Web

BACKGROUND

Evidence-based trauma-focused interventions for treating PTSD in children and youth are barely used in practice. Web-based training has proven to be an effective way of transferring knowledge to healthcare professionals.

OBJECTIVE

TF-CBT Web is a web-based training programme designed to foster the dissemination of Trauma Focused Cognitive Behavioural Therapy (TF-CBT) for children and youth, and is run by the Medical University of South Carolina. This paper describes the characteristics of healthcare professionals who registered for the adapted German language version of TF-CBT Web. It evaluates the effectiveness and user friendliness of the programme.

METHOD

: Similar to the TF-CBT treatment manual, the German language TF-CBT Web contains 12 modules. Between 2018 and 2020, 4,020 users registered for the programme. During the registration process users provided demographic information. The knowledge of users regarding the TF-CBT components was assessed via pre-tests and post-tests in each module.

RESULTS

The programme was accessed by a sample of mostly German users with varying professional health care backgrounds and a wide-ranging spread of work experience. The results indicated a significant knowledge gain and high rates of user satisfaction with the programme.

CONCLUSIONS

In summary, the results of this study suggested that web-based training is an effective and well-accepted method for knowledge gain in trauma-focused interventions. Future research should evaluate the actual application of the taught methods in clinical practice.

HIGHLIGHTS

Children and adolescents with PTSD require trauma-focused treatment. However, evidence-based interventions for this patient population are barely used. Therefore, it is necessary to expand professional training for the treatment of traumatised children and adolescents.Our evaluation showed the effectiveness and feasibility of a web-based training programme for mental health practitioners in an evidence-based treatment for children and youth with PTSD (TF-CBT). Results show a significant knowledge gain of users who participate in the web-based training programme.The user satisfaction survey also revealed that users found the modus and content of the web-based training applicable and relevant for their clinical practice.

Cognitive Behavioral Therapy for the Eating Disorders

Research findings strongly suggest that cognitive behavioral therapy for the eating disorders (CBT-ED) is more effective than other treatments for bulimia nervosa (BN) and for binge eating disorder (BED), although interpersonal psychotherapy appears to be equally effective for BED. Evidence for the effectiveness of CBT-ED for the persistent (adult) form of anorexia nervosa (AN) is insufficient at present and is essentially absent for AN in adolescents except for some evidence from uncontrolled trials. This article begins with an overview of the early studies in the development of CBT-ED that showed a similar effectiveness of other symptom-focused psychotherapies-a finding that was neglected at the time. Later developments are then considered, including comparisons of CBT-ED with other psychotherapies, efforts to develop Internet-based training and treatment, and electronic applications for treatment. Finally, implications of the findings for future short- and long-term research and for clinical practice are considered.

The COVID-19 pandemic and eating disorders in children, adolescents, and emerging adults: virtual care recommendations from the Canadian consensus panel during COVID-19 and beyond

OBJECTIVE

The COVID-19 pandemic has had detrimental effects on mental health. Literature on the impact on individuals with eating disorders is slowly emerging. While outpatient eating disorder services in Canada have attempted to transition to virtual care, guidelines related to optimal virtual care in this field are lacking. As such, the objective of our Canadian Consensus Panel was to develop clinical practice guidelines related to the provision of virtual care for children, adolescents, and emerging adults living with an eating disorder, as well as their caregivers, during the COVID-19 pandemic and beyond.

METHODS

Using scoping review methodology (with literature in databases from 2000 to 2020 and grey literature from 2010 to 2020), the Grading of Recommendations, Assessment, Development, and Evaluation system, the Appraisal of Guidelines, Research and Evaluation tool, and a panel of diverse stakeholders from across Canada, we developed high quality treatment guidelines that are focused on virtual interventions for children, adolescents, and emerging adults with eating disorders, and their caregivers.

RESULTS

Strong recommendations were supported specifically in favour of in-person medical evaluation when necessary for children, adolescents, and emerging adults, and that equity-seeking groups and marginalized youth should be provided equal access to treatment. For children and adolescents, weak recommendations were supported for telehealth family-based treatment (FBT) and online guided parental self-help FBT. For emerging adults, internet cognitive-behavioural therapy (CBT)-based guided self-help was strongly recommended. Weak recommendations for emerging adults included CBT-based group internet interventions as treatment adjuncts, internet-based relapse prevention Maudsley Model of Anorexia Nervosa Treatment for Adults (MANTRA) guided self-help, telehealth relapse prevention using MANTRA, and guided CBT-based smartphone apps as treatment adjuncts. For caregivers of children and adolescents, weak recommendations were supported for virtual parent meal support training, and moderated online caregiver forums and support groups. For caregivers of emerging adults, guided parental self-help CBT was strongly recommended, and unguided caregiver psychoeducation self-help was weakly recommended.

CONCLUSIONS

Several gaps for future work were identified including the impact of sex, gender, race, and socioeconomic status on virtual care among children, adolescents, and emerging adults with eating disorders, as well as research on more intensive services, such as virtual day hospitals.

Learning gains from a one-day training in acceptance-based behavior therapy

The primary method of training for individual licensed mental health professionals is continuing education (CE). Despite the promise of CE as a vehicle for training clinicians in evidence-based practices, only a handful of studies have examined the efficacy of trainings delivered in the CE context. Moreover, these studies have focused on a few very specific therapeutic approaches. There is a growing body of evidence supporting Acceptance-based Behavior Therapy (ABBT) as a treatment for generalized anxiety disorder (GAD) and related disorders. Training workshops aimed at disseminating ABBT are regularly conducted across and outside the United States, yet the effectiveness of these trainings is unknown. The goal of this study was to examine learning outcomes among licensed mental health professionals following a six-hour CE training in ABBT. Data were collected at baseline, post-training, and at three-month follow-up. Participants demonstrated a statistically significant increase in learning on an ABBT Knowledge Questionnaire and in their coded responses to client scenarios from baseline to follow-up, although there was a significant decline in knowledge between post and follow-up. Beyond baseline ABBT knowledge, attitude towards evidence-based practice was the only predictor of change in knowledge over time.

E-Learning to Improve Suicide Prevention Practice Skills Among Undergraduate Psychology Students: Randomized Controlled Trial

BACKGROUND

Despite increasing evidence of the effectiveness of digital learning solutions in higher vocational education, including the training of allied health professionals, the impact of Web-based training on the development of practical skills in psychiatry and psychology, in general, and in suicide prevention, specifically, remains largely understudied.

OBJECTIVE

This study aimed to determine the effectiveness of an electronic learning (e-learning) module on the adherence to suicide prevention guidelines, knowledge of practical skills, and provider's confidence to have a conversation about suicidal behavior with undergraduate psychology students.

METHODS

The e-learning module, comprising video recordings of therapist-patient interactions, was designed with the aim of transferring knowledge about suicide prevention guideline recommendations. The program's effects on guideline adherence, self-evaluated knowledge, and provider's confidence were assessed using online questionnaires before the program (baseline and at 1 month [T1] and 3 months after baseline). The eligible third- and fourth-year undergraduate psychology students were randomly allocated to the e-learning (n=211) or to a waitlist control condition (n=187), with access to the intervention after T1.

RESULTS

Overall, the students evaluated e-learning in a fairly positive manner. The intention-to-treat analysis showed that the students in the intervention condition (n=211) reported higher levels of self-evaluated knowledge, provider's confidence, and guideline adherence than those in the waitlist control condition (n=187) after receiving the e-learning module (all P values<.001). When comparing the scores at the 1- and 3-month follow-up, after both groups had received access to the e-learning module, the completers-only analysis showed that the levels of knowledge, guideline adherence, and confidence remained constant (all P values>.05) within the intervention group, whereas a significant improvement was observed in the waitlist control group (all P values<.05).

CONCLUSIONS

An e-learning intervention on suicide prevention could be an effective first step toward improved knowledge of clinical skills. The learning outcomes of a stand-alone module were found to be similar to those of a training that combined e-learning with a face-to-face training, with the advantages of flexibility and low costs.

PTSD as a Public Mental Health Priority

PURPOSE OF REVIEW

This article reviews recent evidence related to public health epidemiology and intervention for traumatic stress and PTSD. Recent evidence is presented regarding incidence of traumatic stress worldwide, as well as most frequent types of traumas, indicators of the public health burden of PTSD, and prevalence, predictors, and correlates of PTSD. Public health perspectives on intervention and treatment are delineated, and innovations in both psychosocial and psychopharmacological interventions are highlighted.

RECENT FINDINGS

PTSD has been associated with substantial medical and economic burden. Recent public health preventive innovations include integrated medical/behavioral health care, acute CBT and attention interventions, modifications to CBT protocols, use of novel and augmentative psychopharmacological agents, and use of technology. Recent research regarding the scope and impact of traumatic stress, as well as prevention strategies for PTSD, have resulted in an improved understanding of its impact and more effective public health interventions.

Innovative Models in Mental Health Delivery Systems: Task Sharing Care with Non-specialist Providers to Close the Mental Health Treatment Gap

PURPOSE OF REVIEW

Most people do not have access to adequate mental health care, and lack of skilled human resources is a major factor. We provide a narrative review of approaches to implementing task sharing-engaging non-specialist providers-to deliver mental health care.

RECENT FINDINGS

There is strong evidence both for the effectiveness of task sharing as a means of delivering care for a range of conditions across settings and for the effectiveness of non-specialist providers and health workers in delivering elements of culturally adapted psychosocial and psychological interventions for common and severe mental disorders. Key approaches to facilitate task sharing of care include balanced care, collaborative care, sustained training and supervision, use of trans-diagnostic interventions based on a dimensional approach to wellness and illness, and the use of emerging digital technologies. Non-specialist providers and health workers are well positioned to deliver evidence-based interventions for mental disorders, and a variety of delivery approaches can support, facilitate, and sustain this innovation. These approaches should be used, and evaluated, to increase access to mental health services.