Implementation Science and Practice-Oriented Research: Convergence and Complementarity

Implementation science is the scientific study of methods to promote the uptake of research findings and other evidence-based practices in routine care, with the goal of improving the quality and effectiveness of health services (Bauer et al., 2015). In addition to this common goal, practice-oriented psychotherapy research (and researchers) and implementation science (and scientists) share a common focus on the people and the places where treatment happens. Thus, there exists strong potential for combining these two approaches. In this article, we provide a primer on implementation science for psychotherapy researchers and highlight important areas and examples of convergence and complementarity between implementation science and practice-oriented psychotherapy research. Specifically, we (a) define and describe the core features of implementation science; (b) discuss similarities and areas of complementarity between implementation science and practice-oriented psychotherapy research; (c) discuss a case example that exemplifies the integration of implementation science and practice-oriented research; and (d) propose directions for future research and collaborations that leverage both implementation science and practice-oriented research.

Practice-Oriented Research: An Introduction to New Developments and Future Directions

Aimed at understanding and improving psychological therapies as they are conducted in clinical routine, practice-oriented research (POR) is now a well-established approach to the scientific foundations of mental health care services. Resting on the accumulation of a wide range of practice-based evidence related to treatment outcome and process, as well as factors associated with the participants of psychotherapy and its context, POR is ripe for new developments - regarding what to investigate and how to investigate it. This paper is the introduction of a series devoted to recent advances and future directions of POR as their pertained to routine outcome monitoring, technologies and artificial intelligence, the integration of constructs and methods from program evaluation and implementation science, and the investigation of populations with limited financial resources across various regions of the world. The series also includes commentaries from two leaders of POR.

Preferences for e-Mental Health Interventions in Germany: A Discrete Choice Experiment

OBJECTIVES

Recent evidence suggests that e-mental health interventions can be effective at improving mental health but that there is still a notable hesitation among patients to use them. Previous research has revealed that they are perceived by patients as being less helpful than face-to-face psychotherapy. The reasons for this unfavorable perception are, however, not yet well understood. The aim of our study was to address this question by eliciting preferences for individual components of e-mental health interventions in a discrete choice experiment.

METHODS

Using a stepwise qualitative approach, we developed the following 5 attributes of eMHIs: introductory training, human contact, peer support, proven effectiveness, content delivery, and price. Additionally, we asked questions about respondents' demographics, attitudes, and previous experience of traditional psychotherapy, as well as their distress level.

RESULTS

A total of 1984 respondents completed the survey. Using mixed logit models, we found that personal contact with a psychotherapist in blended care, proven effectiveness, and low price were highly valued by participants. Participants were indifferent toward the mode of content delivery but showed a slight preference for introductory training via phone, as well as for peer support via online forum alongside coach-led group meetings on site.

DISCUSSION

Our results suggest a clear preference for blended care that includes face-to-face contact with a psychotherapist. This preference remained stable irrespective of sociodemographics, previous experience of psychotherapy, distress level, and the 2 context scenarios used in our discrete choice experiment. Further investigations looking at the potential benefits and risks of blended care are needed.

Introducing SYPRENE: An International Practice Research Network for Strategic and Systemic Therapists and Researchers

SYPRENE, a new international Systemic Practice Research Network (PRN), has been established to fill the gap in practice-based research on the effectiveness and efficiency of strategic therapies. This article presents the rationale for the creation of SYPRENE and describes data collection methods, and the encoding system implemented within this PRN. More developments are expected in the recruitment of practitioners, the types of data collected, findings, and the implementation of SYPRENE in supervision, trainings, and professional schools.

The Creation of a Psychiatry-Palliative Care Liaison Team: Using Psychiatrists to Extend Palliative Care Delivery and Access During the COVID-19 Crisis

CONTEXT

During the course of March and April 2020, New York City experienced a surge of a 170,000 coronavirus disease 2019 (COVID-19) cases, overwhelming hospital systems and leading to an unprecedented need for palliative care services.

OBJECTIVES

To present a model for rapid palliative care workforce expansion under crisis conditions, using supervised advanced psychiatry trainees to provide primary palliative services in the acute care and emergency setting.

METHODS

In response to the New York City COVID-19 surge, advanced psychiatry trainees at New York-Presbyterian Columbia University Irving Medical Center were rapidly trained and redeployed to a newly formed psychiatry-palliative care liaison team. Under the supervision of consultation-liaison psychiatrists (who also served as team coordinators), these trainees provided circumscribed palliative care services to patients and/or their families, including goals-of-care discussions and psychosocial support. Palliative care attendings remained available to all team members for more advanced and specialized supervision.

RESULTS

The psychiatry-palliative care liaison team effectively provided palliative care services during the early phase and peak of New York City's COVID-19 crisis, managing up to 16 new cases per day and provided longitudinal follow-up, thereby enabling palliative care specialists to focus on providing services requiring specialist-level palliative care expertise.

CONCLUSION

By training and supervising psychiatrists and advanced psychiatry trainees in specific palliative care roles, palliative care teams could more effectively meet markedly increased service needs of varying complexity during the COVID-19 crisis. As new geographic regions experience possible COVID-19 surges in the coming months, this may serve as a model for rapidly increasing palliative care workforce.

Clinical Supervision of Couple and Family Therapy during COVID-19

This paper addresses the need for a swift transition from in-person clinical supervision to telesupervision during the time of the COVID-19 global pandemic. Five specific areas will be discussed in the effort to enhance the quality of clinical supervision provided to couple and family therapists in training at this time including the following: (1) COVID-19 and the structural changes and technological adaptation of supervision; (2) culturally and contextually sensitive guidelines for clinical supervision during COVID-19; (3) the supervisee's competence and the clinical supervisory process; (4) the new set of boundaries and the supervisory role; (5) and the supervisory alliance and supervisees' vulnerabilities in the face of COVID-19.

Behind the (Virtual) Mirror: Online Live Supervision in Couple and Family Therapy

Online therapy and supervision, a rapidly rising practice in couple and family therapy, has been the subject of a growing body of literature. From its early days, family therapy training has included live supervision, which has typically been conducted by a supervisor and a team of trainees situated on the other side of a one-way mirror. With the outbreak of the COVID-19 global pandemic, we-the staff of supervisors at the Barcai Institute in Tel Aviv, Israel-were compelled to find solutions to continue meeting with clients and to provide supervision for family therapy trainees. To this end, we have shifted our live supervision courses ("practicums") to the virtual arena, adapting the popular application "Zoom" into what we call "PractiZoom." Based on over 100 PractiZoom sessions conducted between March and May 2020, involving 14 supervisors and 28 therapists-in-training and their clients, the article reflects on this pioneering online practicum for the online live supervision of therapists with geographically distributed participants. In this article, we outline our operational methods and adaptations for conducting live behind-the-mirror supervision online. Following a short theoretical background, we outline the process of online live supervision, discuss our reflections and those of our trainees on the challenges and possibilities it poses, and offer a number of preliminary conclusions and recommendations.

[Psychopharmacotherapy during the COVID-19 pandemic]

Im Rahmen der aktuellen coronavirus disease 2019(COVID-19)-Pandemie müssen sich viele Bereiche der Medizin umstrukturieren. Dies betrifft auch die Versorgung von Patienten mit psychischen Erkrankungen. Die Therapie psychischer Erkrankungen umfasst psychotherapeutische und psychopharmakologische Interventionen. Letztere können mit einer Vielzahl an unerwünschten Arzneimittelwirkungen (UAW) assoziiert sein, stellen aber in der aktuellen Situation mit Kontakt- und Ausgangsbeschränkungen die präferierte Therapieoption dar. Da der direkte Patientenkontakt zugunsten des Telefonats oder der Videokonferenz reduziert ist, müssen angepasste diagnostische und therapeutische Optionen gefunden werden, um eine ausreichende Patientensicherheit zu gewährleisten. Bedeutend sind hierbei die ausführliche Aufklärung der Patienten sowie eine aktive Abfrage von Symptomen zur rechtzeitigen Erkennung von UAW. Unter der Behandlung mit Psychopharmaka sind UAW zu befürchten, die besonders ungünstig sind, wenn sie im Rahmen einer akuten Infektion auftreten oder ein erhöhtes Infektionsrisiko begünstigen. Hierzu gehören Atemdepression, Agranulozytose, Intoxikation durch Hemmung des Arzneistoffmetabolismus und venöse Thromboembolien, die jeweils mit potenziell lebensbedrohlichen Folgen einhergehen. Gleichzeitig sollte auf eine ausreichende Wirksamkeit der Medikation geachtet werden, da die gegenwärtige Krise zu einer Exazerbation vorbestehender psychischer Erkrankungen führen bzw. deren Erstmanifestation begünstigen kann.

The impact of an integrated depression and HIV treatment program on mental health and HIV care outcomes among people newly initiating antiretroviral therapy in Malawi

BACKGROUND

Depression is highly prevalent among patients newly starting antiretroviral treatment (ART) in Malawi and many other countries. Untreated depression at ART initiation can disrupt the HIV care continuum. Effective approaches for depression screening and treatment exist for low-resource settings, but they are rarely applied. Identifying effective implementation strategies are critical.

METHODS

A pilot program integrated depression screening and treatment into routine HIV care using existing staff at two public health clinics in Malawi in two phases; a screening-only "control" phase and an active "intervention" phase. During the intervention phase, providers prescribed antidepressants or referred patients for Friendship Bench problem-solving therapy. We evaluated the program's impact on retention in HIV care, viral suppression, and depression remission at 6 months using tabular comparisons and log-binomial models to estimate adjusted risk ratios and mean differences among the intervention group relative to the control group.

RESULTS

Nearly all consenting participants were screened for depression appropriately and 25% had mild to severe depressive symptoms. During the intervention phase, 86% of participants with mild depressive symptoms started Friendship Bench therapy and 96% of participants with moderate to severe depressive symptoms started antidepressants. Few participants in the intervention group received consistent depression treatment over their first 6 months in care. In the adjusted main analysis, program exposure did not demonstrably affect most HIV or mental health outcomes, though the probability of currently being on ART at 6 months was significantly lower among the intervention group than the control group [RR 0.6(95%CI: 0.4-0.9)].

CONCLUSIONS

While it is feasible to integrate depression screening and treatment initiation into ART initiation, providing ongoing depression treatment over time is challenging. Similar implementation science studies focused on maintaining depression management will be increasingly important as we strive to understand and test the best ways to implement evidence-based depression treatment within HIV care.

Online psychosocial interventions for posttreatment cancer survivors: an international evidence review and update

PURPOSE OF REVIEW

The present review describes recent research on online psychosocial interventions for posttreatment cancer survivors from January 2018 to June 2019.

RECENT FINDINGS

Twenty-three studies were included in the review (the majority included were feasibility studies and only five randomized controlled trials had large samples). Websites were the most common platforms for intervention delivery (9/23) and cognitive behavioral therapy was the most frequently used therapeutic approach (11/23). Three interventions based on this framework and delivered via websites or combined website-telehealth platforms showed to be effective in improving psychosocial issues (fear of cancer recurrence, insomnia, sleep quality, and prospective memory failures) in posttreatment cancer survivors. Web-based self-compassion writing was also found to be effective in addressing body image distress and body appreciation in breast cancer survivors. Feasibility studies mostly showed online interventions to be plausible and acceptable to cancer survivors. A good representation of online interventions for young adult cancer survivors (30%) was found.

SUMMARY

Online interventions show promise in addressing the psychosocial needs of cancer survivors. Despite new online interventions being found to be feasible and acceptable and some showing promise in addressing important psychosocial issues in cancer survivors posttreatment, more rigorous studies are required to inform supportive care for this population.

The Ohio State University Early Psychosis Intervention Center (EPICENTER) step-based care programme for individuals at clinical high risk for psychosis: study protocol for an observational study

INTRODUCTION

In October 2018, the Substance Abuse and Mental Health Services Administration funded 21 sites throughout the USA to develop, implement and evaluate specialised care programmes for individuals at clinical high risk for developing a psychotic disorder (CHR-P). Per the funding requirements, such programmes were required to provide 'step-based care'-a model in which individuals are initially provided with low-intensity, non-psychosis-specific and more benign (ie, least side effects) interventions and only progress onto higher-intensity, psychosis-specific interventions with a greater risk of more severe side effects should they not meet a priori criteria for clinical response to such lower-intensity interventions. Here, we outline the evaluation component of the step-based care programme for individuals at CHR-P at The Ohio State University Early Psychosis Intervention Center (EPICENTER).

METHODS AND ANALYSES

The EPICENTER CHR-P programme provides a step-based care model comprising psychotherapy, medication management, family support/education, peer support and vocational/educational support. All participants who opt to receive care at the EPICENTER will complete a standardised assessment battery as part of usual care. This battery will be administered on enrolment and will be re-administered at 6-month intervals throughout individuals' participation in EPICENTER clinical services. Participants will have the opportunity to allow for data from these usual care assessments to be used as part of an evaluation project for this new clinical service. The primary outcome for this evaluation project is time to remission of symptomatic and functional deficits commonly experienced by individuals at CHR-P. Participants will also have the opportunity to participate in a supplemental research project designed to further evaluate treatment outcomes and patient characteristics among individuals participating in EPICENTER clinical services.

ETHICS AND DISSEMINATION

This project was approved by The Ohio State University Institutional Review Board. Results from this project will be disseminated through publications and presentations.

TRIAL REGISTRATION NUMBER

NCT03970005; Pre-results.

[The modern features of organization of hospital-substituting psychiatric care]

The article presents results of study of issues of psychiatric care organization in mental hospital in 2015-2017. The structure, age distribution and social status of patients are analyzed on the basis of data from Psychiatric Hospital № 13 of the Moscow Health Care Department.

Exploring the role of external experts in supporting staff to implement psychosocial interventions in care home settings: results from the process evaluation of a randomized controlled trial

BACKGROUND

Psychosocial interventions offer opportunities to improve care for people with dementia in care homes. However, implementation is often led by staff who are not well prepared for the role. Some interventions use external experts to support staff. However little is known about external expert, care home staff and manager perceptions of such support. This paper addresses this gap.

METHODS

Multi-methods study within a process evaluation of a cluster randomised controlled trial of Dementia Care Mapping™ (DCM). Interviews were conducted with six external experts who also completed questionnaires, 17 care home managers and 25 care home staff responsible for DCM implementation. Data were analysed using descriptive statistics and template analysis.

RESULTS

Three themes were identified: the need for expert support, practicalities of support and broader impacts of providing support. Expert support was vital for successful DCM implementation, although the five-days provided was felt to be insufficient. Some homes felt the support was inflexible and did not consider their individual needs. Practical challenges of experts being located at a geographical distance from the care homes, limited when and how support was available. Experts gained knowledge they were able to then apply in delivering DCM training. Experts were not able to accurately predict which homes would be able to implement DCM independently in future cycles.

CONCLUSIONS

An external expert may form a key component of successful implementation of psychosocial interventions in care home settings. Future research should explore optimal use of the expert role.

Therapy the Natural Way: A Realist Exploration of the Wilderness Therapy Treatment Process in Adolescent Mental Health Care in Norway

Wilderness therapy has the potential to meet the specific needs of the current adolescent population by providing a rather unique outdoor group treatment. Wilderness therapy is not a new approach to mental health treatment, but its theoretical basis is not yet clearly delineated, in part because of the diversity found across programs and contexts. This article presents a critical realist exploration of a wilderness therapy program that was recently implemented as part of adolescent mental health services in Southern Norway. In this study, we combine fieldwork and interviews for an in-depth investigation of the treatment process, where the objective was to acquire a deeper understanding of the opportunities that arise in the wilderness therapy setting. The therapeutic mechanisms and influential contextual premises found across the ecological, physical, and psychosocial factors of this multidimensional approach to treatment are presented, and their underlying conditions are briefly discussed.

Expanding access to psychotherapy in Canada: Building on achievements in Australia and the United Kingdom

Australia and the United Kingdom have significantly expanded access to psychotherapy over the past decade. With this international experience to draw upon and a new $5 billion federal mental health transfer, Canada is well positioned to address long-standing gaps and inequities in access to psychotherapy. In Canada's more decentralized context, a concerted effort from health leaders at all levels of government and across multiple sectors and professions is needed to make the most of this opportunity for reform. Key priorities for health leaders include using the full range of provincial and territorial policy levers for either a grants-based or insurance-based approach; implementing a strong approach to performance monitoring, with equity targets built in from the outset; addressing gaps in workforce planning; and forming a pan-Canadian coalition for expanding access to psychotherapy.

Perceived risks and use of psychotherapy via telemedicine for patients at risk for suicide

INTRODUCTION

Suicide is a major public health problem and its human, emotional, and economic costs are significant. Individuals in rural areas are at highest risk for suicide. However, telemedicine services are typically not rendered to individuals who are actively suicidal. The goals of the current study were to identify the risks of using telemedicine for mental healthcare from the perspective of licensed mental health providers and to determine factors associated with the use of telemedicine with patients who are at high risk for suicide.

METHODS

A total of 52 licensed mental health providers were recruited online through several professional organization listservs and targeted emails. Providers completed online questionnaires regarding demographics, caseload of suicidal patients, perceived risks for using telemedicine with patients at risk for suicide, attitudes towards telemedicine, and use of telemedicine with patients at risk for suicide.

RESULTS

Three key perceived risks associated with using telemedicine were identified, including assessment, lack of control over patient, and difficulties triaging patients if needed. It was also found that individuals who had more positive attitudes towards telemedicine, younger providers, and more experienced providers were more likely to use telemedicine with patients who are at high risk for suicide.

DISCUSSION

To our knowledge, this is the first study to examine the perceived risks and use of telemedicine with patients at high risk for suicide. It is essential to continue this line of research to develop protocols for the provision of evidence-based therapy via telemedicine for this high-risk group.

"Why Come for Treatment?" Clients' and Therapists' Accounts of the Presenting Problems When Seeking Mental Health Care

Although identification of main problems is the foundation for treatment planning, limited research has examined reasons for seeking mental health care. We identified reasons for seeking mental health care as reported by clients and therapists upon initial contact with mental health services. We conducted in-depth interviews with clients and their therapists immediately following the intake. We analyzed 117 therapist and 112 client interviews using thematic analysis. Overall interrater reliability among three raters who coded the interviews was high (kappa = 0.72). Our findings suggest that, overall, clients and therapists report similar main area problems that bring clients to care. Emotional distress and other psychiatric symptoms as well as interpersonal problems were most prevalent. Therapists tended to ignore some problem areas that clients highlighted, including physical problems and socioeconomic strains. Raising awareness to potential gaps in perception of main problems that bring clients to care will promote a shared understanding and improve quality of care.

[Adherence and alleance: psychoanalytic observations at the service of medicine.]

About the relationship between medicine and psychoanalysis it has been written a lot, in primis in the psycho-somatic perspective, in secundis in the psychic modulation of health and disease. In this paper a different perspective is adopted. Both psychoanalysis and medicine are currently confronted with different patients than in the past, indeed nowadays patients are often more fragile, as in the somatic as in the psychic problems. For this reason in both disciplines the theme of adherence to treatment is very important, to which the theme of the relationship is linked. The aim of this work is to contaminate medical thinking about adherence with concepts, surveys, observations, that psychoanalysis has developed about its patients. In other words, we propose a declination in the medical field of some reflections that psychoanalysts and psychotherapists have elaborated about the adherence of their patients.

A Patient-Centered Approach to a Rural General Practice in Distress and the Search for a Solution

CONTEXT

A general practice in rural UK (Cumbria) was overwhelmed by staff burnout.

OBJECTIVE

To present a case study for how the staff of a practice came together, used data, agreed on a plan for improvement, implemented the plan, improved subjective distress, and objectively evaluated the intervention.

DESIGN

We conducted an audit using the electronic health record for patients coming to the practice 5 or more times annually from 2008 to 2012 (frequent attenders). We planned an intervention to reduce utilization (frequency of visits) while still serving patients. The intervention used a genogram, psychoeducation, and up to six 30-minute sessions of solutions-focused psychotherapy, in which difficult interpersonal relationships were identified and efforts were made to resolve 1 major problem related to those relationships.

MAIN OUTCOME MEASURES

Quantitative data (number of visits per year) and qualitative data about the changes that resulted in the practice from the audit and the intervention.

RESULTS

The frequency of visits for patients with mental health conditions (41.0% of all frequent attenders in the practice) dropped significantly from 2007 to 2012 (p = 0.019; initial visits per year, 10.0, standard deviation = 2.51; final visits per year = 5.6, standard deviation = 3.8). The frequency of visits for patients without mental health diagnoses did not change.

CONCLUSION

Intervening with frequent attenders of primary care who have mental health conditions improved their symptoms and reduced their health care utilization, with beneficial impact on practitioners and improvement in the morale of the staff.

A Randomized Controlled Trial of Family Finding: A Relative Search and Engagement Intervention for Youth Lingering in Foster Care

BACKGROUND

Youth who have experienced foster care are at risk of negative outcomes in adulthood. The family finding model aims to promote more positive outcomes by finding and engaging relatives of children in foster care in order to provide options for legal and emotional permanency.

OBJECTIVES

The present study tested whether family finding, as implemented in North Carolina from 2008 through 2011, improved child welfare outcomes for youth at risk of emancipating foster care without permanency.

RESEARCH DESIGN

A randomized controlled trial evaluation was carried out in nine counties in North Carolina. All children eligible for intervention services between 2008 and 2011 underwent random assignment. Effects were tested with an intent-to-treat design. Outcome data were obtained for all subjects from child welfare administrative data. Additional outcome data for a subset of older youth came from in-person interviews.

SUBJECTS

Subjects included 568 children who were in foster care, were 10-17 years old (at time of referral), had no identified permanent placement resource, and had no plan for reunification.

MEASURES

The confirmatory outcome was moves to more family-like placements, whether through a step-down in foster care placement or discharge from foster care to legal permanency.

RESULTS

No impact on the confirmatory outcome was observed. Findings regarding exploratory impacts are also described; these must be interpreted with caution, given the large number of outcomes compared.

CONCLUSIONS

The evaluation failed to find evidence that family finding improves the outcomes of older youth at risk of emancipation from foster care.

[The early recognition of mental morbidities during psycho-oncologic treatment]

Unfortunately there have been no positive changes in the main indicators of cancer incidence in Hungarian population since the turn of the millennium. The main goal of psycho-oncologic treatment is to provide the highest possible quality of life to the patient. The prevalence of mental disorders in cancer patients is high and it is accompanied by a rather small number of qualified staff. Thus, the remedy might be the identification of high-risk patients, i.e. the systematic psycho-oncologic screening. Hungary is still lacking a unified screening method that involves all oncologic treatment-providing units. Compiling the Hungarian standards for the Distress Thermometer and the Problem List is the first step of a complex program for creating a general psycho-oncologic screening. Such a comprehensive program might improve oncologic patient-care and, eventually, the quality and prospect of the lives of patients.

[Areas and challenges of oncopsychological rehabilitation]

Patients with cancer present a number of different difficulties that adversely affect their health care and recovery (e.g. poor communication with physicians, lack of knowledge about their illness and its management, financial problems). Furthermore, mental health problems, such as distress, depression and anxiety, are common amongst patients with cancer. These mental health problems are additional contributors to functional impairment in carrying out family, work, and other social roles, poor adherence to medical treatments, and adverse medical outcomes. Oncopsychosocial rehabilitation aims to optimize the possibilities of medical health care through psychological interventions by helping cancer patients and their families and/or health care workers with the management of the psychological and social aspects of the illness. Oncopsychosocial rehabilitation includes all psychosocial interventions that are designed to positively influence patient psychosocial adaptation and adjustment to diagnosis, treatment, and survivorship. Oncopsychological rehabilitation could also manage cancer related distress and other psychosocial problems with specific types of treatments or interventions including prevention, relaxation techniques, structured psychoeducational interventions including sexual information and/or preparation for surgery, and various methods of psychotherapy.

Impact on the psychotic vulnerability of the therapeutic approachin the Prison Psychiatric Hospital in Seville (Spain)

OBJECTIVES

to analyze changes in psychotic vulnerability following the implementation of a program of prison psychiatric treatment, recidivism after the release and various descriptive variables of criminological interest.

MATERIALS AND METHODS

review of a sample consisting of 50 patients diagnosed with schizophrenia admitted to the Prison Psychiatric Hospital of Seville.

RESULTS

there was a statistically significant reduction of psychotic vulnerability according to an assessment using the Frankfurt psychopathological inventory (FBF-3), after conducting a complete psychiatric, psychological, social and rehabilitation approach in the prison environment. The core symptoms relating to complex perception and language also decreased significantly. The reduction is particularly noticeable in the number of patients categorized as medium-high and high severity. Recidivism in the follow-up of release of patients in the study sample is low (6%) and there were no cases of serious felony or grievous bodily harm. Recidivism, when it occurs, is not immediate. Although there is some criminal versatility, it is limited. The most frequent victims are parents with a previous relationship with the patient. Most of the patients in the sample, and all recidivists, have comorbid substance abuse (dual diagnosis).

DISCUSSION

we need more comprehensive studies to establish causal relationships between the decrease in psychotic vulnerability and an integrated psychiatric, psychological, social and rehabilitation approach in prisons; or to attribute the low rate of recidivism to the decline of psychotic vulnerability.

Nationwide Interdisciplinary E-Consultation on Transgender Care in the Veterans Health Administration

BACKGROUND

Veteran's Health Administration (VHA) requires the provision of quality transgender care for the relatively large number of transgender veterans using VHA services.

INTRODUCTION

The Office of Patient Care Services has taken a multimethod approach to improving provider knowledge and skill for transgender veteran care. However, unique patient-specific questions can arise. Thus, VHA implemented a 3-year feasibility program to determine if nationwide interdisciplinary e-consultation can offer veteran-specific consultation to providers who treat transgender veterans in VHA.

MATERIALS AND METHODS

Launch of this program is described along with use to date, types of questions submitted by providers, and length of time to complete a response in the veteran's electronic medical record.

RESULTS

In 17 months, the program responded to 303 e-consults, with consultation provided on the care of 230 unique veterans. Nationwide coverage was achieved 1 year after the launch of the program. Common consult questions have been about medications, including hormones (n = 125); primary care concerns (n = 97); mental health evaluations (n = 63); and psychotherapy (n = 18). Consistent with the interdisciplinary model, multiple disciplines typically responded to each consult (x = 2.27). Average time to completion of a consult was 5.9 calendar days (range = 2.4-7.7 days).

DISCUSSION

VHA has established a nationwide interdisciplinary e-consultation program. Additional outreach about the program will be needed if funding is continued.

CONCLUSIONS

E-consultation on transgender health within VHA is feasible and complements the suite of trainings offered within VHA. Other healthcare organizations may benefit from a similar program.

[Health and justice coordination in prisons]

The question of health-justice coordination has been present since the law of 18th January 1994. Since then, professional relations between prison staff and health carers have been regularly questioned in terms of their aims. The texts structuring this interinstitutional health-justice coordination constitutes a framework which the various professionals must appropriate and implement by drawing on specific knowledge and skills. It is an invitation to work together around the same population, on their respective and different missions. The implementation of a structured therapeutic group with sex offenders constitutes a positive experience.

ESCAP Expert Article: borderline personality disorder in adolescence: an expert research review with implications for clinical practice

Borderline personality disorder (BPD) has onset in adolescence, but is typically first diagnosed in young adulthood. This paper provides a narrative review of the current evidence on diagnosis, comorbidity, phenomenology and treatment of BPD in adolescence. Instruments available for diagnosis are reviewed and their strengths and limitations discussed. Having confirmed the robustness of the diagnosis and the potential for its reliable clinical assessment, we then explore current understandings of the mechanisms of the disorder and focus on neurobiological underpinnings and research on psychological mechanisms. Findings are accumulating to suggest that adolescent BPD has an underpinning biology that is similar in some ways to adult BPD but differs in some critical features. Evidence for interventions focuses on psychological therapies. Several encouraging research studies suggest that early effective treatment is possible. Treatment development has just begun, and while adolescent-specific interventions are still in the process of evolution, most existing therapies represent adaptations of adult models to this developmental phase. There is also a significant opportunity for prevention, albeit there are few data to date to support such initiatives. This review emphasizes that there can be no justification for failing to make an early diagnosis of this enduring and pervasive problem.

Resilient Systemics to Telehealth Support for Clinical Psychiatry and Psychology

Reliably expanding our clinical practice and lowering our overhead with telepsychiatry, telepsychology, distance counseling and online therapy, requires resilient and antifragile system and tools. When utilized appropriately these technologies may provide greater access to needed services to include more reliable treatment, consultation, supervision, and training. The wise and proper use of technology is fundamental to create and boost outstanding social results. We present, as an example, the main steps to achieve application resilience and antifragility at system level, for diagnostic and therapeutic telepractice and telehealth support, devoted to psychiatry and psychology application. This article presents a number of innovations that can take psychotherapy treatment, supervision, training, and research forward, towards increased effectiveness application.

[From the editor - epidemiology of mental diseases]

Od redakcji

Towards Resilient Telehealth Support for Clinical Psychiatry and Psychology: A Strategic Review

Human beings have increasingly shown a willingness to adopt Internet, mHealth and telehealth applications as a part of managing their health. Recent technological advances in the use of the Internet and video technologies has greatly impacted the provision of psychotherapy and other clinical services as well as how the training of psychotherapists may be conducted. When utilized appropriately these technologies may provide greater access to needed services to include treatment, consultation, supervision, and training. The major issue in such a development is whether online interventions will be structured or unstructured. The proper use of technology is fundamental to create and boost outstanding results. We present a strategic review and, as an example, the main steps to develop and achieve application resilience and antifragility at system level, for diagnostic and therapeutic telepractice and telehealth support. This article presents a number of innovations that can take psychotherapy treatment, supervision, training, and research forward, towards increased effectiveness application.

[The personality structure as a basis for the organization of psychological support in the process of medical rehabilitation of the patients presenting with motor function disorders]

We have analyzed the relationships between personality traits and the quality of life in 95 in-patients with motor function disorders undergoing the rehabilitative treatment. It was shown that the high quality of life in the patients suffering from motor function disorders as a result of an acute cerebral circulation disorder correlated with the positive attitudes towards recovering and stress resistance. In the patients presenting with degenerative-dystrophic diseases of the joints, the high quality of life correlated with the purpose-oriented behaviour and discipline expressed as the commitment to the goal. It was suggested based on the results of the study that the correction of the level of situational and trait anxiety should be regarded as the main end-point of the psychological treatment of the patients with acute cerebral circulation disorders, while the patients suffering from degenerative-dystrophic diseases of the joints could benefit from education designed to enhance compliance to the treatment and motivation for recovery.

Psychotherapy: a profile of current occupational therapy practice in Ontario

BACKGROUND

Psychotherapy can be an important part of psychosocial occupational therapy practice; however, it requires specialized training to achieve and maintain competence. Regulation varies by province, and in Ontario, occupational therapists were recently authorized to perform psychotherapy.

PURPOSE

The purpose of this study was to explore the psychotherapy practice, training, and support needs of Ontario occupational therapists.

METHOD

An online survey was sent to occupational therapists who had clients with mental health or chronic pain issues, asking about their expertise and support needs in relation to nine psychotherapy approaches.

FINDINGS

Of the 331 therapists who responded, there were variations in the nature and frequency of psychotherapy practice. Experienced therapists in outpatient settings were more likely to practice psychotherapy, and cognitive-behaviour therapy, motivational interviewing, and mindfulness were the most common approaches. Supervision and training varied, with many therapists interested in occupational therapy-specific training.

IMPLICATIONS

Recommendations for a framework of support include education about the nature of psychotherapy, training and supervision guidelines, and advocacy for occupational therapy and psychotherapy.

Treating without diagnosis: Psychoanalysis in medical settings in Argentina

This article is part of a larger research project, the aim of which is to understand the discursive conditions of access and adherence to an outpatient mental health service at a public hospital in Buenos Aires, Argentina. The focus is on the historical conflict between medical discourse and psychoanalytical discourse as it emerges in the negotiation of treatment and diagnostic sequences at first consultations. It can be seen that patients who are socialized in medical discourse--and even in psychiatric discourse--expect the usual procedure in which a diagnosis, however transitory, is offered first and then followed by a treatment recommendation. However, psychoanalysts, in contrast, tend to reject diagnostic labels and offer treatment without further justification. This has an impact on the adherence of patients, and we can argue for the need to negotiate with medical discourse in order to guarantee engagement and continuity in treatment.

Team work as the way to back up consciousness

Conception of unconsciousness after brain injury had changed considerably due to high technologies. Nowadays some patients considered by clinicians as unconscious are admitted to awareness with neurovisual techniques. Physiologic and neurophysiologic signals' combining brings forward robust quantification of patients' clinical state too. These "Third Person View" approaches leave the question of patient's experience content open because of determined stimuli paradigms. Yet patient's response pattern becomes formed not only with brain deficits but by questions-stimuli, context, and inquiring person. Rehabilitation team work is sourcing of phenomenology knowledge of patient's processes due to "First-Second Person View" approach and chance to real-time change. Restoration of consciousness comes of building-up patients' contacts with their own bodies, other persons and outward things. The basic principle of this approach is feedback assignement to any minimal movement or vegetative signal of the patient. The net of feedbacks with the patient and inter-professional ones builds up the team as Non-linear Complex System. Characteristics of "Team-Patient" system status are energy, entropy, and complexity. Impairment of consciousness as the absence of linear contact with a patient may appear together with a loss of essential functions (low energy), vegetative-visceral fits (excessive energy and low order), motor agitation (excessive energy and order), and etc. Techniques of team work are different in these cases for resulting optimization of the system condition. System complexity rise is a powerful tool to arouse apatient with impairment of consciousness. System self-organization is a key process for awareness formation. Analysis of complex communication process in patient--team system may be useful for creation of the general theory of consciousness.

[Psycho-oncological care for melanoma patients: conception and implementation]

Offering psycho-oncological care is an essential, guideline-based component of comprehensive care in skin cancer centers. This paper describes the development, implementation and utilization of a specific psycho-oncologic care concept for melanoma patients in the University Dermatology Clinic Freiburg. Based on the stepped-care principle, the concept is composed of interdisciplinary group sessions for patients and their relatives offered every 4-6 weeks addressing medical and psycho-oncological topics related to treatment of malignant melanoma and then individual psycho-oncological sessions modified for the patient's treatment needs. Between April 2010 and July 2012, 67 % of the melanoma patients treated in the Freiburg Skin Cancer Center were reached by the program. A stepped-care concept with a routinely initiated first contact and low-threshold patient education group sessions is a reliable approach to reach patients and inform them about further psycho-oncological care. The advantages justify the allocation of resources and the approach proved successful for routine clinical practice.

Feasibility evaluation of an interpersonal and social rhythm therapy group delivery model

The effectiveness of psychotherapies, such as interpersonal and social rhythm therapy (IPSRT), is supported by randomized controlled trials. These trials provide minimal direction regarding feasibility of psychotherapy delivery models. The study purpose was to identify factors facilitating implementation and sustainability of an IPRST group for patients with bipolar disorder. Qualitative data were assessed by the normalization process model (NPM). The results demonstrate feasibility of implementation with experienced clinicians, program coordination, and leadership support. Sustainability challenges include aftercare groups, space, and clinician time. The NPM provides a useful framework for evaluation of factors influencing the feasibility of psychotherapy delivery models.

[From the psychiatric sector to the mental health territory]

There is currently a noticeable change in public health policy, as well as a paradigm shift with the policy of a mental health territory. From a humanist sector policy, centred on the patient, we are moving towards a policy of a mental health territory, which, although taking into account the changing needs of a group of people, no longer considers the specific needs of the individual. The notion of a geographic breakdown of the organisation of care is becoming predominant.