Reflections on Treatment Integrity in a Dissemination and Implementation Framework

This commentary reflects on issues related to linking the conceptual frame for treatment fidelity presented in the special issue articles to the most current thinking on treatment fidelity within the emerging field of implementation science. The commentary presents several aspects of treatment fidelity in implementation science that generally were not discussed or addressed in the special issue articles, such as the placement of treatment fidelity as only one among several critical implementation outcomes, the relationship of treatment fidelity to design elements such as external validity as well as internal validity, and the importance of considering implementation issues in the measurement of treatment fidelity even in the earlier stages of efficacy and effectiveness research. The excellent in‐depth discussion of treatment fidelity in the special series is a promising start to linking this critical concept to the emerging field of implementation science.     

Making a Case for Treatment Integrity as a Psychosocial Treatment Quality Indicator for Youth Mental Health Care

Measures of treatment integrity are needed to advance clinical research in general and are viewed as particularly relevant for dissemination and implementation research. Although some efforts to develop such measures are underway, a conceptual and methodological framework will help guide these efforts. The purpose of this article is to demonstrate how frameworks adapted from the psychosocial treatment, therapy process, healthcare, and business literatures can be used to address this gap. We propose that components of treatment integrity (i.e., adherence, differentiation, competence, alliance, client involvement) pulled from the treatment technology and process literatures can be used as quality indicators of treatment implementation and thereby guide quality improvement efforts in practice settings. Further, we discuss how treatment integrity indices can be used in feedback systems that utilize benchmarking to expedite the process of translating evidence‐based practices to service settings.     

The evidence-based practice of psychotherapy: Facing the challenges that lie ahead

What does the future hold for psychotherapy research and practice? We review some key influences, including declining psychotherapy utilization, increasing impact of evidence-based medical practices, over-medicalizing of mental health problems, and changing priorities from grant funding agencies. These factors hold potential opportunities but also major pitfalls that will need to be carefully navigated related to implementation/dissemination issues, interdisciplinary collaborations, and psychosocial versus biomedical perspectives related to the nature and treatment of psychopathology. In addition, we review and comment on the other articles contained in this special issue pertaining to the future of evidence-based psychotherapy.     

Using Treatment Integrity Methods to Study the Implementation Process

[Clin Psychol Sci Prac 18: 36–40, 2011] The last decade has witnessed increased interest in the implementation and dissemination of evidence‐based treatments (EBTs) for youth. Nakamura et al. (2011) detail lessons learned over the past decade from the large‐scale implementation of EBTs for children in Hawaii. This commentary discusses how lessons from Hawaii’s initiative can help inform the next generation of implementation research. Specifically, we focus on how treatment integrity models and methods designed to characterize core aspects of treatment delivery can be used to study the implementation process. Using the new interactive online reporting systems developed by Nakamura et al. to collect treatment integrity data offers researchers a way to determine how best to implement EBTs in community‐based service settings with integrity and skill.     

The place of implementation science in the translational medicine continuum

There is a growing consensus that the transfer of knowledge from biomedical discoveries into patient and public benefit should be accelerated. At the same time there is a persistent lack of conceptual clarity about the precise nature of the phases of the translational continuum necessary to implement this. In this paper, we: (i) propose an integrated schema to understand the five sequential phases that link basic biomedical research with clinical science and implementation; (ii) discuss the nature of three blocks along this translational pathway; (iii) outline key issues that need to be addressed in removing such barriers. The five research phases described are: (0) basic science discovery; (1) early human studies; (2) early clinical trials; (3) late clinical trials; (4) implementation (which includes adoption in principle, early implementation and persistence of implementation). This schema also sets out three points at which communication blocks can occur. The application of 'implementation science' is in its early stages within mental health and psychiatric research. This paper therefore aims to develop a consistent terminology to understand the discovery, development, dissemination and implementation of new interventions. By better understanding the factors that promote or delay knowledge to flow across these blocks, we can accelerate progression along translational medicine pathways and so realize earlier patient benefit.     

Behavioral neuroscience and the media

To provide assurance that accurate summaries of behavioral neuroscience findings are presented in mainstream news sources, it is important for scientists to cooperate with science journalists and, on occasion, write informative articles for lay audiences or contribute scientific knowledge in other relevant venues. Accordingly, three influential science journalists were invited to a special Presidential Symposium at the 2011 IBNS annual meeting to discuss (1) the importance of public dissemination of scientific knowledge, (2) insightful recommendations for effective science writing for mainstream audiences and (3) the potential impact of science blogs on the communication of science information.     

Implementation science approaches for integrating eHealth research into practice and policy

PurposeTo summarize key issues in the eHealth field from an implementation science perspective and to highlight illustrative processes, examples and key directions to help more rapidly integrate research, policy and practice.MethodsWe present background on implementation science models and emerging principles; discuss implications for eHealth research; provide examples of practical designs, measures and exemplar studies that address key implementation science issues; and make recommendations for ways to more rapidly develop and test eHealth interventions as well as future research, policy and practice.ResultsThe pace of eHealth research has generally not kept up with technological advances, and many of our designs, methods and funding mechanisms are incapable of providing the types of rapid and relevant information needed. Although there has been substantial eHealth research conducted with positive short-term results, several key implementation and dissemination issues such as representativeness, cost, unintended consequences, impact on health inequities, and sustainability have not been addressed or reported. Examples of studies in several of these areas are summarized to demonstrate this is possible.ConclusionseHealth research that is intended to translate into policy and practice should be more contextual, report more on setting factors, employ more responsive and pragmatic designs and report results more transparently on issues important to potential adopting patients, clinicians and organizational decision makers. We outline an alternative development and assessment model, summarize implementation science findings that can help focus attention, and call for different types of more rapid and relevant research and funding mechanisms.     

Don't Mourn: Organize. Reviving Mental Health Services Research for Healthcare Quality Improvement

The structure, organization, management, and design of the mental health system are changing profoundly as new healthcare policies reshape its configurations. This special issue is a call to action for the mental health services research field. The articles represent an important attempt to identify specific concepts, constructs, and findings from psychosocial treatment research about fidelity and integrity of treatment and align them with healthcare quality. However, the current structure and processes for deriving quality indicators place other demands on the extant research base. These will challenge this migration unless changes are made in leadership around consistent measurement strategies, payment mechanisms to support quality, and attention to technological infrastructure development. The mental health services research field should be proactive. Pediatric issues need special attention, especially as applied to community‐based services for children and their families.     

Personality Disorders in Adolescence: Label or Opportunity?

The articles in this special issue testify to the rapidly growing body of research concerning the assessment and treatment of personality disorders (PDs) in adolescence. In this commentary, we will first attempt to summarize what we consider to be the overall take‐home messages of the articles in this issue in the context of current limitations in our knowledge of PDs in adolescence. Further, we comment on the gap between science and practice in this field, stressing the importance of diagnosing PDs in adolescence. We close with some thoughts and recommendations concerning the future of research on PDs in adolescence.     

Gene-targeted therapies: Overview and implications

Gene-targeted therapies (GTTs) are therapeutic platforms that are in principle applicable to large numbers of monogenic diseases. The rapid development and implementation of GTTs have profound implications for rare monogenic disease therapy development. This article provides a brief summary of the primary types of GTTs and a brief overview of the current state of the science. It also serves as a primer for the articles in this special issue.     

The role of organizational behavior in occupational health psychology: a view as we approach the millennium

This special section of the Journal of Occupational Health Psychology provides ample illustration of the increasingly important role of organizational behavior research on work-related issues of health and well-being. More specifically, the 9 articles contained in this special section highlight the varied application and potentially widespread benefit of considering the main effects of employee physical health and psychological well-being. The authors conclude with a discussion of how emerging research issues in occupational health psychology can be used to build a stronger science of organizational behavior.     

Ethical Challenges in Community-Based Research: Introduction to the Series

We describe the inspiration for this series of articles and articulate several themes that run throughout the four articles that follow. Particular ethical challenges in community-based mental health research are identified, as is the tension between existing ethical codes and policies and the requirements of more collaborative, community-based research. We edited this special series with an eye toward promoting greater discussion of ethical issues in this realm and the eventual development and promotion of guidelines for ethical decision-making in community-based research.     

In the Know and in the News: How Science and the Media Communicate About Stem Cells,Autism and Cerebral Palsy

Stem cell research has generated considerable attention for its potential to remediate many disorders of the central nervous system including neurodevelopmental disorders such as autism spectrum disorder (ASD) and cerebral palsy (CP) that place a high burden on individual children, families and society. Here we characterized messaging about the use of stem cells for ASD and CP in news media articles and concurrent dissemination of discoveries through conventional science discourse. We searched LexisNexis and Canadian Newsstand for news articles from the US, UK, Canada and Australia in the period between 2000 and 2014, and PubMed for peer reviewed articles for the same 10 years. Using in-depth content analysis methods, we found less cautionary messaging about stem cells for ASD and CP in the resulting sample of 73 media articles than in the sample of 87 science papers, and a privileging of benefits over risk. News media also present stem cells as ready for clinical application to treat these neurodevelopmental disorders, even while the science literature calls for further research. Investigative news reports that explicitly quote researchers, however, provide the most accurate information to actual science news. The hope, hype, and promise of stem cell interventions for neurodevelopmental disorders, combined with the extreme vulnerability of these children and their families, creates a perfect storm in which journalists and stem cell scientists must commit to a continued, if not even more robust, partnership to promote balanced and accurate messaging.     

Introduction: Reprioritizing the role of science in a realistic version of the scientist-practitioner model

This series of articles attempts to redefine and reprioritize the role of science in search for a clinically meaningful and realistic version of the scientist-practitioner (S-P) model. To this end, science is discussed as both research-driven practice and clinically meaningful research, keeping practitioners and their needs in the center of attention. In this process, common problems in the actualization of the S-P model are discussed, and potential solutions are offered.     

Introduction: the International Conference on Intelligent Biology and Medicine (ICIBM) 2016: special focus on medical informatics and big data

In this editorial, we first summarize the 2016 International Conference on Intelligent Biology and Medicine (ICIBM 2016) held on December 8–10, 2016 in Houston, Texas, USA, and then briefly introduce the ten research articles included in this supplement issue. At ICIBM 2016, a special theme, “Medical Informatics and Big Data,” was dedicated to the recent advances of data science in the medical domain. After peer review, ten articles were selected for this special issue, covering topics such as Knowledge and Data Personalization, Social Media Applications to Healthcare, Clinical Natural Language Processing, Patient Safety Analyses, and Data Mining Using Electronic Health Records.     

Evidence-Based Psychosocial Treatments for Children and Adolescents With Attention Deficit/Hyperactivity Disorder

The purpose of this research was to update the series of articles on evidence-based treatment for children and adolescents with attention deficit/hyperactivity disorder that have appeared in this journal (Evans, Owens & Bunford, 2014; Pelham & Fabiano, 2008; Pelham, Wheeler, & Chronis, 1998). We completed a systematic review of the literature published between 2012 and 2016 to establish levels of evidence for psychosocial treatments for these youth. We identified articles using criteria established by the Society of Clinical Child and Adolescent Psychology using keyword searches of abstracts and titles. Articles were classified according to a modified version of the Division 12 task force guidelines that was used in other reviews in this series. The results revealed that findings are becoming increasingly nuanced with variations in levels of evidence related to ages of the children and characteristics of the specific treatment. In addition, we focused our critique on generalization of treatment effects across settings and time and on sample diversity (with regard to ethnicity and levels of parent education) in relation to the population. Children of parents with higher levels of education than average appear to be overrepresented in the literature. Implications for future treatment development and evaluation and for dissemination research are discussed.     

Treatment integrity in psychotherapy research: analysis of the studies and examination of the associated factors

Treatment integrity refers to the degree to which an intervention is delivered as intended. Two studies evaluated the adequacy of treatment integrity procedures (including establishing, assessing, evaluating, and reporting integrity; therapist treatment adherence; and therapist competence) implemented in psychotherapy research, as well as predictors of their implementation. Randomized controlled trials of psychosocial interventions published in 6 influential psychological and psychiatric journals were reviewed and coded for treatment integrity implementation. Results indicate that investigations that systematically addressed treatment integrity procedures are virtually absent in the literature. Treatment integrity was adequately addressed for only 3.50% of the evaluated psychosocial interventions. Journal of publication and treatment approach predicted integrity implementation. Skill-building treatments (e.g., cognitive-behavioral) as compared with non-skill-building interventions (e.g., psychodynamic, nondirective counseling) were implemented with higher attention to integrity procedures. Guidelines for implementation of treatment integrity procedures need to be reevaluated.     

Adherence and Flexibility: They Can (and Do) Coexist!

[Clin Psychol Sci Prac 17: 258–264, 2010] Using their experiences disseminating the Triple P parenting program, Mazzucchelli and Sanders (2010) make a strong case for how flexibility enhances provider satisfaction, critical thinking about intervention delivery, and most importantly, adherence and fidelity. Their article makes an outstanding and innovative contribution to the literature on implementation research, advancing the field to a view of flexibility as a feature that may facilitate adherence. In this commentary, we place Mazzucchelli and Sanders’s work within the context of ongoing implementation research. We also call for embedding questions about implementation science into effectiveness trials to better inform dissemination efforts aimed at facilitating provider adoption and adherence to empirically supported treatments.     

The current state of implementation science in genomic medicine: opportunities for improvement

PurposeThe objective of this study was to identify trends and gaps in the field of implementation science in genomic medicine.MethodsWe conducted a literature review using the Centers for Disease Control and Prevention’s Public Health Genomics Knowledge Base to examine the current literature in the field of implementation science in genomic medicine. We selected original research articles based on specific inclusion criteria and then abstracted information about study design, genomic medicine, and implementation outcomes. Data were aggregated, and trends and gaps in the literature were discussed.ResultsOur final review encompassed 283 articles published in 2014, the majority of which described uptake (35.7%, n = 101) and preferences (36.4%, n = 103) regarding genomic technologies, particularly oncology (35%, n = 99). Key study design elements, such as racial/ethnic composition of study populations, were underreported in studies. Few studies incorporated implementation science theoretical frameworks, sustainability measures, or capacity building.ConclusionAlthough genomic discovery provides the potential for population health benefit, the current knowledge base around implementation to turn this promise into a reality is severely limited. Current gaps in the literature demonstrate a need to apply implementation science principles to genomic medicine in order to deliver on the promise of precision medicine.Genet Med advance online publication 12 January 2017