The impact of module dosage on treatment response in a modular transdiagnostic intervention for sleep and circadian dysfunction (TranS-C)

The efficacy of modular evidence-based psychological treatments is promising, yet variation in module delivery is understudied. This study evaluated module delivery of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) and its impact on patient outcomes. Adults (N = 108) with serious mental illness and sleep and circadian dysfunction treated in a community setting were randomized to receive TranS-C plus usual care, or 6 months of usual care followed by delayed treatment with TranS-C. Data from both conditions were combined to maximize power. These secondary analyses tested whether the "dosage" of module delivery (defined as the proportion of total sessions in which a module was delivered) predicted treatment response, measured as functional impairment, psychiatric symptoms, sleep and circadian dysfunction, and sleep health, at post-treatment and 6-month follow-up. Higher dosages of seven modules were associated with improvement in the outcome variables (βs = -0.11-0.44; ps = 0.000-0.030). Higher dosages of three modules were associated with a worsening of one or two outcome variables (βs = 0.22-0.29; ps = 0.001-0.043). Higher dosages of the remaining modules were not associated with outcomes. Although more evidence is needed, it may be wise to consider focusing provider trainings on ensuring fidelity to certain modules, given limited training time in community settings. ClinicalTrials.gov Identifier: NCT02469233, registered June 9, 2015.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: study protocol for a hybrid type 2 effectiveness-implementation cluster-randomized trial using train-the-trainer

BACKGROUND

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes and (b) providers' perceptions of fit.

METHODS

TTT will be implemented in nine CMHCs in California, USA (N = 60 providers; N = 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality), and (3) evaluate other possible moderators.

DISCUSSION

This trial has potential to (a) inform the process of embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) add to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advance our understanding of providers' perceptions of EBPT "fit" across TTT generations.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT05805657 . Registered on April 10, 2023.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 2: Study protocol for a hybrid type 2 effectiveness-implementation cluster- randomized trial using train-the-trainer

Background

Train-the-trainer (TTT) is a promising method for implementing evidence-based psychological treatments (EBPTs) in community mental health centers (CMHCs). In TTT, expert trainers train locally embedded individuals (i.e., Generation 1 providers) to deliver an EBPT, who then train others (i.e., Generation 2 providers). The present study will evaluate implementation and effectiveness outcomes of an EBPT for sleep and circadian dysfunction-the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C)-delivered to CMHC patients with serious mental illness by Generation 2 providers (i.e., trained and supervised within CMHCs via TTT). Specifically, we will investigate whether adapting TranS-C to fit CMHC contexts improves Generation 2 (a) patient outcomes (b) providers' perceptions of fit.

Methods

TTT will be implemented in nine CMHCs in California, United States (N= 60 providers; N= 130 patients) via facilitation. CMHCs are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each CMHC, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will assess the effectiveness of TranS-C (combined Adapted and Standard), compared to UC-DT, on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms for Generation 2 patients. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to Generation 2 providers' perceptions of fit. Aim 3 will evaluate whether Generation 2 providers' perceived fit mediates the relation between TranS-C treatment condition and patient outcomes. Exploratory analyses will: (1) evaluate whether the effectiveness of TranS-C for patient outcomes is moderated by generation, (2) compare Adapted and Standard TranS-C on patient perceptions of credibility/improvement and PhenX Toolkit outcomes (e.g., substance use, suicidality); and (3) evaluate other possible moderators.

Discussion

This trial has potential to inform the process of (a) embedding local trainers and supervisors to expand delivery of a promising transdiagnostic treatment for sleep and circadian dysfunction, (b) adding to the growing body of TTT literature by evaluating TTT outcomes with a novel treatment and population, and (c) advancing our understanding of providers' perceptions of EBPT 'fit' across TTT generations.

Trial registration

Clinicaltrials.gov identifier: NCT05805657. Registered on April 10, 2023. https://clinicaltrials.gov/ct2/show/NCT05805657.

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) for serious mental illness in community mental health part 1: study protocol for a hybrid type 2 effectiveness-implementation cluster-randomized trial

BACKGROUND

Serious mental illness (SMI) can have devastating consequences. Unfortunately, many patients with SMI do not receive evidence-based psychological treatment (EBPTs) in routine practice settings. One barrier is poor "fit" between EBPTs and contexts in which they are implemented. The present study will evaluate implementation and effectiveness outcomes of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) implemented in community mental health centers (CMHCs). TranS-C was designed to target a range of SMI diagnoses by addressing a probable mechanism and predictor of SMI: sleep and circadian problems. We will investigate whether adapting TranS-C to fit CMHC contexts improves providers' perceptions of fit and patient outcomes.

METHODS

TranS-C will be implemented in at least ten counties in California, USA (N = 96 providers; N = 576 clients), via facilitation. CMHC sites are cluster-randomized by county to Adapted TranS-C or Standard TranS-C. Within each county, patients are randomized to immediate TranS-C or usual care followed by delayed treatment with TranS-C (UC-DT). Aim 1 will compare TranS-C (combined Adapted and Standard) with UC-DT on improvements in sleep and circadian problems, functional impairment, and psychiatric symptoms. Sleep and circadian problems will also be tested as a mediator between treatment condition (combined TranS-C versus UC-DT) and functional impairment/psychiatric symptoms. Aim 2 will evaluate whether Adapted TranS-C is superior to Standard TranS-C with respect to provider perceptions of fit. Aim 3 will evaluate whether the relation between TranS-C treatment condition (Adapted versus Standard) and patient outcomes is mediated by better provider perceptions of fit in the Adapted condition. Exploratory analyses will (1) compare Adapted versus Standard TranS-C on patient perceptions of credibility/improvement and select PhenX Toolkit outcomes and (2) evaluate possible moderators.

DISCUSSION

This trial has the potential to (a) expand support for TranS-C, a promising transdiagnostic treatment delivered to patients with SMI in CMHCs; (b) take steps toward addressing challenges faced by providers in delivering EBPTs (i.e., high caseloads, complex patients, poor fit); and (c) advance evidence on causal strategies (i.e., adapting treatments to fit context) in implementation science.

TRIAL REGISTRATION

Clinicaltrials.gov NCT04154631. Registered on 6 November 2019. https://clinicaltrials.gov/ct2/show/NCT04154631.

Study protocol for a randomized trial of bridge: Person-centered collaborative care for serious mental illness and cancer

BACKGROUND

Individuals with serious mental illness (SMI) experience inequities in cancer care that contribute to increased cancer mortality. Involving mental health at the time of cancer diagnosis may improve cancer care delivery for patients with SMI yet access to care remains challenging. Collaborative care is a promising approach to integrate mental health and cancer care that has not yet been studied in this marginalized population.

METHODS/DESIGN

We describe a 24-week, two-arm, single-site randomized trial of person-centered collaborative care (Bridge) for patients with SMI (schizophrenia, bipolar disorder, or major depression with psychiatric hospitalization) and their caregivers. 120 patients are randomized 1:1 to Bridge or Enhanced Usual Care (EUC) along with their caregivers. Researchers proactively identify individuals with SMI and a new breast, lung, gastrointestinal, or head and neck cancer that can be treated with curative intent. EUC includes informing oncologists about the patient's psychiatric diagnosis, notifying patients about available psychosocial services, and tracking patient and caregiver outcomes. Bridge includes a proactive assessment by psychiatry and social work, a person-centered, team approach including collaboration between mental health and oncology, and increased access to evidence-based psycho-oncology care. The primary outcome is cancer care disruptions evaluated by a blinded panel of oncologists. Secondary outcomes include patient and caregiver-reported outcomes and healthcare utilization. Barriers to Bridge implementation and dissemination are assessed using mixed methods.

DISCUSSION

This trial will inform efforts to systematically identify individuals with SMI and cancer and generate the first experimental evidence for the impact of person-centered collaborative care on cancer care for this underserved population.

Applying the Science of Habit Formation to Evidence-Based Psychological Treatments for Mental Illness

Habits affect nearly every aspect of our physical and mental health. Although the science of habit formation has long been of interest to psychological scientists across disciplines, we propose that applications to clinical psychological science have been insufficiently explored. In particular, evidence-based psychological treatments (EBPTs) are interventions targeting psychological processes that cause and/or maintain mental illness and that have been developed and evaluated scientifically. An implicit goal of EBPTs is to disrupt unwanted habits and develop desired habits. However, there has been insufficient attention given to habit-formation principles, theories, and measures in the development and delivery of EBTPs. Herein we consider whether outcomes following an EBPT would greatly improve if the basic science of habit formation were more fully leveraged. We distill six ingredients that are central to habit formation and demonstrate how these ingredients are relevant to EBPTs. We highlight practice points and an agenda for future research. We propose that there is an urgent need for research to guide the application of the science of habit formation and disruption to the complex "real-life" habits that are the essence of EBPTs.

COVID-19 Prevention via the Science of Habit Formation

The coronavirus disease 2019 (COVID-19) continues to claim lives worldwide. We propose that the science of habit formation offers strategies to increase adherence to COVID-19 prevention behaviors and has the potential to be lifesaving, particularly for high-risk groups. Eight elements of habit formation are highlighted here: addressing incorrect beliefs, setting goals, devising an action plan, establishing contextual cues, adding reinforcement, engaging in repetition, aiming for automaticity, and recognizing that change is difficult. In addition, we offer a set of strategies for forming new habits and eliminating existing habits to contain the spread of COVID-19. These strategies are derived from habit-formation principles and behavior-change techniques and can inform future research on treatment development. With the COVID-19 pandemic still raging, there is currently an urgent need to jump-start the state of knowledge on habit-formation processes and interventions.

Bridge: Person-Centered Collaborative Care for Patients with Serious Mental Illness and Cancer

BACKGROUND

Individuals with serious mental illness (SMI) experience increased cancer mortality due to inequities in cancer treatment. Psychiatric care at cancer diagnosis may improve care delivery, yet models for integrating psychiatry and cancer care are lacking. We assessed the feasibility and acceptability of a person-centered collaborative care trial for SMI and cancer.

SUBJECTS, MATERIALS, AND METHODS

We developed the Bridge intervention for patients with SMI (schizophrenia, bipolar disorder, and severe major depression) and cancer. Bridge includes proactive identification of SMI, person-centered care from a psychiatrist and case manager, and collaboration with oncology. We conducted a 12-week, single-group trial in patients with SMI and a new breast, gastrointestinal, lung, or head/neck cancer. We assessed the feasibility of patient identification, enrollment and study completion; evaluated acceptability and perceived benefit with exit interviews with patients, caregivers, and oncology clinicians; and examined change in psychiatric symptoms with the Brief Psychiatric Rating Scale (BPRS).

RESULTS

From November 2015 to April 2016, 30/33 eligible patients (90.9%) enrolled, and 25/29 (86.2%) completed assessments at all timepoints, meeting feasibility criteria. Of 24 patients, 23 (95.8%) found meeting with the psychiatrist helpful; 16/19 caregivers (84.2%) shared that Bridge addressed key caregiving challenges. Oncology clinicians evaluated Bridge as "very" or "most" useful for 94.3% of patients. Exit interviews with all participant groups suggested that Bridge fostered patient-clinician trust, increased access to psychiatric treatment, and enabled patients to initiate and complete cancer treatment. Psychiatric symptoms on the BPRS improved from baseline to 12 weeks.

CONCLUSION

Bridge is a feasible and acceptable care delivery model for patients with SMI, their caregivers, and oncology clinicians. Randomized trials are warranted to assess the efficacy of improving cancer outcomes in this underserved population.

IMPLICATIONS FOR PRACTICE

Serious mental illness affects 13 million U.S. adults who experience increased cancer mortality. To improve outcomes, new models of integrated oncology and mental health care are urgently needed. This study found that it was feasible to identify, enroll, and retain patients with serious mental illness and a new cancer in a trial of integrated mental health and cancer care (Bridge). Patients, caregivers, and oncologists reported that Bridge facilitated the initiation and completion of cancer care. Randomized trials are warranted to investigate the impact on cancer outcomes. Trial procedures may inform consent, engagement, and trial retention for patients with mental illness.

Randomized trial protocol of bridge intervention for patients with serious mental illness and cancer

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Background: Individuals with serious mental illness (SMI) diagnosed with cancer often have disruptions in treatment, leading to premature mortality compared to patients without SMI. To address such gaps in care, we developed and piloted a collaborative care intervention for patients with SMI and cancer (Bridge). We now propose a randomized controlled trial (RCT) to investigate the impact of the Bridge intervention on disruptions in cancer care for patients with SMI. Methods: We will conduct a two-arm RCT (n = 120) comparing Bridge to enhanced usual care (EUC) for patients with SMI (schizophrenia, bipolar disorder, major depressive disorder) and newly diagnosed breast, lung, gastrointestinal, or head/neck cancer. The 12-week Bridge intervention includes: 1) assessment by a psychiatrist with expertise in oncology at cancer diagnosis, 2) involvement of a case manager to promote self-management and care coordination, 3) collaboration between psychiatry and oncology (e.g., joint visits, developing an integrated treatment plan) to address barriers to care, and 4) availability of study clinicians via phone, text, or in-person for consultation and follow-up with patients, caregivers, and oncology and community mental health clinicians. In the EUC arm, study staff will inform the treating oncologist of the psychiatric diagnosis and notify the patient and oncologist of available psychosocial services at enrollment. Patients will be randomized 1:1 to Bridge or EUC, stratified by presence of a caregiver. Identified caregivers will be co-enrolled, and patients without a caregiver will be eligible. We will utilize verbal consent, link study visits to oncology appointments, and personalize frequency and location (e.g., community, clinic, hospital) of contact with patients and caregivers to decrease burden and promote engagement. The primary outcome is the proportion of patients with disruptions in cancer care within 6 months of enrollment, confirmed by oncologists blinded to study arm. Secondary outcomes include clinician assessment of psychiatric illness severity as well as patient and caregiver reported measures (e.g., depression, engagement in care, treatment satisfaction). Results: N/A. Conclusions: N/A. Clinical trial information: NCT03360695.