Integrating Interventions and Services Research: Progress and Prospects

Although interventions and services research paradigms have distinct historical roots and methodologic traditions, both aim to improve mental health services for adults and youth. This article introduces a series of articles that represent examples of innovative and integrative (i.e., integration of services and interventions research) research efforts. This work involves an integration of the interventions and services research paradigms to address the difficult questions related to improving mental health services in diverse settings. Each of the four articles takes a distinctly different path in bringing together the interventions and services research traditions, with foci ranging from (a) using psychotherapy measurement tools to assess the content of usual care practice in collaboration with providers, (b) adapting randomized clinical trial design to fit nonmental healthcare settings while addressing relevant outcomes, (c) understanding and incorporating patient preferences into treatment research, and (d) identifying organization-level variables relevant to interventions development and implementation. In the introductory article, we provide a brief précis concerning the interventions and services research traditions, highlight how each of the four articles illustrates an innovative integration of interventions and services research, and discuss additional future directions beyond the work introduced in this series.     

Mental health intervention programs in primary care: their scientific basis.

This study examines the scientific basis for mental health intervention programs in primary care. The validity of five underlying assumptions is evaluated, using the results of a naturalistic study covering a representative sample of 25 Dutch family practices and data from the literature. Our findings corroborate the validity of the assumptions. Firstly, our study indicates that mental disorders are indeed very prevalent in primary care settings. Secondly, we find that a substantial proportion of mental disorders is not recognized by the general practitioner (GP). Thirdly, our data show that mental disorders in primary care are not transient or self-limiting. Fourthly, it is shown that only half of the GP attenders with a mental disorder receive some form of mental health treatment in the 14 months after their index consultation. Finally, our data suggest that mental disorders, when identified, can be treated effectively in primary care. These findings are in general agreement with the literature. In the discussion we underscore the need for public health intervention programs targeted at primary care providers. Training programs for general physicians must be directed at improving recognition and diagnosis and at enhancing the availability and quality of mental health interventions. The effectiveness of these programs has to be tested in randomized trials.     

Examining Psychotherapy Processes in a Services Research Context

Interdisciplinary research efforts integrating services and interventions research methodologies are needed to improve the "real-world" clinical utility and impact of youth mental health research. "Hybrid" services and interventions research efforts can capitalize on the methodologic strengths of each research tradition in order to more rigorously examine and affect therapy processes in usual care youth mental health service settings. The goals of this article are to (a) identify the need for hybrid practice research on youth mental health care; (b) present a "case example" of a hybrid study, where child and family therapy processes are being examined in a usual care, practice-based context by a team of services researchers; (c) address the potential advantages and challenges of hybrid research; and (d) suggest promising areas for future hybrid research in youth mental health care.     

Smoking cessation: what have we learned over the past decade?

This article discusses developments in understanding smoking and smoking cessation, methodological issues, and intervention approaches over the past 10 years. Although effective multisession clinic interventions have been developed, such programs reach relatively few smokers. This has led to self-help, work site, health care setting, and community interventions aimed at delivering less intensive programs to larger populations. Conceptual and empirical developments and trends within these above delivery contexts are reviewed, and avenues of research are identified. Nicotine replacement strategies have benefited from technological advances (e.g., transdermal patches) and present continuing challenges with respect to integration with behavioral strategies and incorporation into primary care medical settings. Research over the next decade should focus on the development of cost-effective interventions that can reach representative and high-risk smokers.     

A randomized controlled trial and economic evaluation of counselling in primary care.

BACKGROUND: Counselling in primary care settings remains largely unevaluated. Such evaluation has been strongly recommended. AIM: To determine the relative effectiveness and cost-effectiveness of generic counselling and usual general practitioner (GP) care for patients with minor mental health problems. METHOD: A randomized controlled trial and health economic evaluation were carried out in nine general practices. Access to generic counselling (brief counselling, generally involving up to six 50-minute sessions) was compared with usual GP care. A total of 162 patients aged 16 years and over with diverse mental health problems (excluding phobic conditions and psychoses) were randomized. The Hospital Anxiety and Depression (HAD) scale, COOP/WONCA (World Organization of Family Doctors) functional health assessment charts, and the delighted-terrible faces scale were used to assess outcome four months after randomization. RESULTS: The two groups were similar at baseline. There were significant improvements in both groups between randomization and follow-up for most outcome measures, but no significant differences between the study arms. The 95% confidence limits were narrow and excluded clinically significant effects. Under various assumptions concerning the cost of secondary care referrals and of counselling time, no clear cost advantage was associated with either intervention. CONCLUSIONS: This pragmatic trial demonstrates no difference in functional or mental health outcome at four months between subjects offered access to counselling and those given usual care by their GP. There is no clear difference in the cost-effectiveness of the two interventions. Purchasers should take account of these findings in allocating resources within primary care.     

Early intervention services in youth mental health

Mental and substance use disorders are leading contributors to the burden of disease among young people in Australia, but young people experience a range of barriers to accessing appropriate treatment for their mental health concerns. The development of early intervention services that provide accessible and effective mental health care has the potential to reduce the individual and community burden associated with mental health problems. Collaborative care arrangements between general practitioners, psychologists and other service providers are a key component of comprehensive and integrated early intervention services, with evidence-based psychological treatments an important part of these collaborative mental health care models. Recently, the Australian Government funded headspace (the National Youth Mental Health Foundation) to promote and support early intervention in youth mental health by establishing accessible and collaborative models of enhanced primary mental health care for young people with emergent mental and substance use disorders. Clinical psychologists in the headspace Community of Youth Service and other settings will play a key role in providing early and effective interventions within multidisciplinary collaborative care arrangements.     

Behavioral Health Services in Primary Care: A New Perspective for Treating Depression

This article attempts to provide information, inspiration, and practical guidelines for mental health professionals who want to work with primary care providers. Depression is an ideal initial focus in starting primary care behavioral services because (1) the majority of currently available efficacy studies on primary care behavioral hearth interventions concern depression and (2) depression is highly prevalent in the primary care setting. Several large clinical trials indicate that on-site mental health services help primary care providers improve quality of care to depressed primary care patients. This article examines five key questions and suggests two service delivery models to help mental health providers plan initiatives that Integrate medical and behavioral health care in the primary care setting.     

Principles of effectiveness trials and their implementation in VA Cooperative Study #430: 'Reducing the efficacy-effectiveness gap in bipolar disorder'

Despite the availability of efficacious treatments for bipolar disorder, their effectiveness in general clinical practice is greatly attenuated, resulting in what has been called an 'efficacy-effectiveness gap'. In designing VA Cooperative Studies Program (CSP) Study #430 to address this gap, nine principles for conducting an effectiveness (in contrast to an efficacy) study were identified. These principles are presented and discussed, with specific aspects of CSP #430 serving as illustrations of how they can be implemented in an actual study. CSP #430 hypothesizes that an integrated, clinic-based treatment delivery system that emphasizes (1) algorithm-driven somatotherapy, (2) standardized patient education, and (3) easy access to a single primary mental health care provider to maximize continuity-of-care, will address the efficacy-effectiveness gap and improve disease, functional, and economic outcome. It is an 11-site, randomized controlled clinical trial of this multi-modal, clinic-based intervention versus usual VA care running from 1997 to 2003. The trial has enrolled 191 subjects in each arm, using minimal exclusion criteria to maximize the external validity of the study. Subjects are followed for 3 years. The intervention is highly specified in a series of operations manuals for each of the three components. Several continuous quality improvement (CQI) interventions, process measures, and statistical techniques deal with drift of care in both the intervention and usual care arms to ensure the internal validity of the study. CSP #430 is designed to have impact well beyond the VA, since it evaluates a basic health care operational principle: that augmenting ambulatory access for major mental illness will improve outcome and reduce overall treatment costs. If results are positive, this study will provide a reason to reconsider the prevailing trend toward limitation of ambulatory services that is characteristic of many managed care systems today.     

Audio-taping the oncology treatment consultation: a literature review

An increased amount of research has been conducted to evaluate interventions for improving the quality of communication between cancer patients and health care providers. One of these interventions involves providing patients with audiotapes of their consultations with oncologists. Given that effective patient-physician communication has been linked to beneficial health outcomes, an examination of studies that have evaluated the effects of audiotape provision appears warranted. This article provides a critical review of this literature. The audiotape intervention has been examined in uncontrolled studies and randomized trials, and the primary outcome variables have included psychological well-being, information recall, and patient satisfaction. The empirical literature is unclear as to the efficacy of providing patients with taped recordings of cancer consultations. Overall, the findings suggest that the majority of patients benefit from receiving the audiotape, but the utility of this intervention in improving patient-physician communication requires further examination. Replication studies and well-controlled experimental designs applied to a variety of health care providers in diverse oncology settings are needed to confirm the validity of the empirical findings to date, and to facilitate further development of interventions aimed at enhancing patient-physician communication.     

Telemental Health: Reflections on How to Move the Field Forward

Richardson, Frueh, Grubaugh, Egede, and Elhai (2009) review recent literature on providing mental health care via videoconferencing. Videoconferencing is one of a growing number of telecommunications technologies used to provide telemental health care. This commentary places videoconferencing in the broader field of telemental health care and discusses some of the areas that are crucial to the advancement of the field. To this end, the assumption that telemental health intervention improves access to care is explored. The notion that different telemental health telecommunications media, including the telephone and Internet, may have different benefits and disadvantages with respect to both efficacy and access is discussed. Existing and emerging telecommunications technologies not only allow us to extend access to mental health care, but they also provide opportunities to develop fundamentally new treatment paradigms. To support this development, we are in need of new theories and conceptual frameworks that can promote the development and evaluation of new telemental health interventions.     

Cluster randomised controlled trial of the effectiveness of primary care mental health workers

BACKGROUND: Mental health issues are a core part of the work of primary care and are the second most common reason for consultations. There is some evidence that the quality of primary care mental health provision is variable. AIM: To evaluate the effectiveness of primary care mental health workers with regards to satisfaction with care, mental health symptoms, use of the voluntary sector, and cost effectiveness of care. DESIGN OF STUDY: Cluster randomised controlled trial. SETTING: Practices in the Heart of Birmingham Primary Care Trust, Birmingham, England. METHOD: Nineteen practices and 368 patients (18 to 65 years of age) with a diagnosis of a new or ongoing common mental health problem were recruited. Sixteen practices and 284 patients completed the trial. RESULTS: Patients in intervention practices had a higher mean level of general satisfaction than those in control practices (difference between group scores of 8.3, 95% confidence interval = 1.3 to 15.3, P = 0.023). The two groups did not differ in mental health symptom scores or use of the voluntary sector. CONCLUSION: For patients with common mental health problems, primary care mental health workers may be effective at increasing satisfaction with an episode of care.     

Clinical utility of cognitive‐behavioural treatment for panic disorder. results obtained in different settings: a research centre and a public mental health care unit

Cognitive‐Behavioural programmes have become the treatment of choice for Panic Disorder (PD). However, although its effectiveness has been widely demonstrated, there are still some limitations regarding the possibility of offering this type of treatment to all panic sufferers. Some researchers are studying ways to make these programmes more available. This study deals with the application and testing of treatment programmes for PD in sites where patients usually look for help for their psychological problems, i.e. mental health care centres. Our work follows a strategy of benchmarking, and the results obtained after applying the treatment in habitual clinical contexts are compared with the results obtained after applying it in research contexts. In the present work, we analyse the possibility of ‘transporting’ a group cognitive‐behavioural programme for PD, developed in a research context, to a more natural setting, a public mental health unit. In this work we present data, using a benchmarking strategy, on one hand, on the differential effectiveness of a group cognitive‐behavioural treatment for PD applied in two different settings: a research setting—a clinical unit at the university; and a natural setting—a public mental health unit. On the other hand, we compare our results with those achieved by other studies carried out in research settings in different countries and a study carried out in a natural setting. Results indicated that our treatment was equally effective in both settings and that effectiveness was comparable to that achieved by the other studies in research and natural settings. Copyright © 2002 John Wiley & Sons, Ltd.     

Psychologists in Long-Term Care: Overview of Practice and Public Policy: Introduction to the Special Series

With the overall aging of the population and the concomitant need for the provision of mental health care for older adults, professional psychology in long-term care has come of age. Psychologists are now increasingly practicing in such traditional long-term care settings as nursing homes and in less traditional ones such as rehabilitation units, day centers, partial hospitaliza-tion programs, and hospices. The practice of psychology in long-term care is strongly influenced by public policy issues relating to Medicare, such as conditions of reimbursement, the rise of managed Medicare, and the continued disparity between payment for mental health and medical diagnoses. Ceropsychologists must be flexible in the form of their healthcare delivery to continue to provide quality services. The following articles in this special section on long-term care summarize the research on assessment and interventions for long-term care patients, outline the training opportunities available, and provide a decision-making framework for the common professional ethical/legal issues encountered in long-term care settings.     

Bringing Psychotherapy to Primary Care: Innovations and Challenges

[Clin Psychol Sci Prac 17: 191–214, 2010] The segregation of mental health treatment and primary medical care in our health care system is increasingly recognized as anachronistic, as a majority of patients with psychosocial problems are turning to primary care providers. Accordingly, the development and dissemination of evidence‐based psychotherapeutic interventions compatible with the constraints of primary care is becoming increasingly urgent. This article discusses the importance of finding feasible ways to bring psychotherapy to primary care, examines interventions either specifically adapted for primary care or consistent with its constraints, assesses the compatibility of these interventions with the primary care environment, considers barriers inhibiting the widespread integration of such interventions into primary care, and discusses future directions.     

Current Directions in Videoconferencing Tele-Mental Health Research

The provision of mental health services via videoconferencing tele-mental health has become an increasingly routine component of mental health service delivery throughout the world. Emphasizing the research literature since 2003, we examine (a) the extent to which the field of tele-mental health has advanced the research agenda previously suggested and (b) implications for tele-mental healthcare delivery for special clinical populations. Previous findings have demonstrated that tele-mental health services are satisfactory to patients, improve outcomes, and are probably cost effective. In the very small number of randomized controlled studies that have been conducted to date, tele-mental health has demonstrated equivalent efficacy compared to face-to-face care in a variety of clinical settings and with specific patient populations. However, methodologically flawed or limited research studies are the norm, and thus the research agenda for tele-mental health has not been fully maximized. Implications for future research and practice are discussed.     

A Little Effort Can Withstand the Hardship: Fielding an Internet-Based Intervention to Prevent Depression among Urban Racial/Ethnic Minority Adolescents in a Primary Care Setting

Background

This study explored the implementation of Chicago Urban Resiliency Building (CURB), a randomized clinical trial designed as an Internet-based primary care depression prevention intervention for urban African American and Latino adolescents.

Behavioral Health Treatment Redesign in Managed Care Settings

This article addresses the general trends and research directions taking place in managed care behavioral health care settings. Such challenges as the demands for accountability and cost-effectiveness have led to the pressing need for (a) sound outcomes measurement systems, (b) standardization of empirically supported treatment protocols, and (c) more concerted efforts to bridge the gap in psychology between efficacy research occurring in controlled, often academic settings, and effectiveness research whereby tested protocols are implemented and evaluated within actual practice settings. The treatment literature of three diagnostic groups—anxiety, mood disorders, and eating disorders—is discussed regarding present empirical support and research directions.     

Psychological Interventions in the Era of Managed Competition

The importance of psychological treatments in forthcoming national health care plans has been deempha-sized in federally sponsored clinical practice guidelines published to date, and questioned by certain policymakers and consumer groups. Many critics impugn the clinical efficacy and effectiveness of psychological treatment compared to drug treatments. This article reviews evidence suggesting that psychological interventions from a variety of theoretical perspectives have demonstrated effectiveness for a wide range of disorders—either alone or, in some cases, in combination with medications. In most cases these treatments are more effective and often longer lasting than credible alternative psychological interventions serving as "psychological placebos." Political and public relations issues, as well as problems with dissemination, must be overcome if the public is to benefit fully from powerful and effective psychological interventions in any national health care plan.     

The role of mental health professionals in multidisciplinary pain rehabilitation programs

The traditional roles of psychologists and mental health therapists are challenged by the comprehensive treatment necessary for patients being treated in multidisciplinary pain rehabilitation programs (MPRPs). Mental health professionals within MPRPs provide direct clinical care but also guide the biopsychosocial model of pain management and cognitive-behavioral interventions for multiple disciplines. Illustrated by a case example of a patient who has complex chronic pain, this article discusses the biopsychosocial approach to pain treatment, structure of multidisciplinary care, major roles of mental health professionals in MPRPs, complexities of treating patients who have pain, and challenges in collaborating with multiple disciplines.