Developing and Implementing Randomized Effectiveness Trials in General Medical Settings

This article discusses the development of two mental health services research programs: one targeting depression treatment in primary care and the other early intervention for posttraumatic stress disorders in acute care. Both programs have used the randomized effectiveness trial to assess the delivery of empirically supported psychotherapeutic and psychopharmacologic interventions in these general medical settings. This article explores the fellowship training, clinical experiences, and conceptual frameworks that have informed the progression of the two research programs. Specific modifications to the traditional randomized clinical trial design employed in the effectiveness trials are discussed. This article concludes with reflection on intervention development trajectories and interdisciplinary team compositions that may facilitate the development of mental health interventions that both derive from the best scientific evidence and can be feasibly delivered in real-world treatment settings.     

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.     

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.     

Information infrastructure for inter-organizational mental health services: an actor network theory analysis of psychiatric rehabilitation

In the supply of mental health services to communities, data and information are managed not only by clinical organizations, but also by welfare state agencies and charities. The aim of this study is to use methods of analysis from actor network theory to identify organizational interventions necessary for the development of an information infrastructure for inter-organizational mental health services. Data was collected in a project aimed at developing an information system that supports inter-organizational psychiatric rehabilitation in a Swedish municipality. Three organizational interventions were identified: an integrated service policy defined by the national government, a common legal framework allowing sharing of high-level client data, and commissioned support for local inter-agency workspaces. It is concluded that organizational interventions must be regarded when configuring an information infrastructure for mental health services. Organizational interventions should also routinely be addressed in systems design methods to be used in inter-organizational settings.     

Correspondence between child dysfunction and program intrusion: Evidence of a continuum of care across five child mental health programs

A fundamental goal of the continuum of care concept is high correspondence between child dysfunction and program intrusiveness. Yet the small body of relevant research has identified major discrepancies. We used the Child Behavior Checklist to compare entry-level behavior problems of children from five child mental health programs sequenced in order of level of intrusiveness: Outpatient clinic, parent training, intensive family preservation services (IFPS), residental care, and inpatient hospitalization. Our results contrast with existing research by showing correspondence between level of child dysfunction and program intrusiveness. A possible reason for our contrasting results is that we included a larger number of mental health programs than were used in previous studies. These results are important because they reflect the continuum of care concept being put into practice and support the assertion that increasing mental health options with alternative community mental health programs increases the chances of appropriate treatment for children in trouble.     

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.     

Forty Years of Engagement Research in Children’s Mental Health Services: Multidimensional Measurement and Practice Elements

Poor engagement in child and adolescent mental health services is a significant public health concern. The purpose of this study was to synthesize the engagement literature using a multidimensional measurement framework to identify practice elements that are associated with improved engagement. We examined 50 randomized controlled trials of interventions targeting treatment engagement in youth mental health services published between 1974 and 2016. We utilized a multidimensional measurement framework that includes five engagement domains (i.e., Relationship, Expectancy, Attendance, Clarity, Homework [REACH]). We also used a distillation method (Chorpita & Daleiden, 2009; Chorpita, Daleiden, & Weisz, 2005) to identify specific practices common to interventions that were effective at increasing engagement within each REACH domain. Engagement was most frequently operationalized in intervention studies as Attendance. Individual practices distilled from effective interventions were successful when used with participants with diverse characteristics in a wide variety of contexts. Importantly, we found unique practice patterns associated with outcomes from each REACH domain. Findings suggest that practices such as assessment, psychoeducation, accessibility promotion, barriers to treatment, and goal setting might be used with all youth and families to promote engagement and that other practices could be introduced on an as-needed basis to target specific engagement domains (e.g., modeling to promote Clarity about therapy; therapist monitoring to promote Homework/participation). A substantial evidence base demonstrates that engagement can be improved through specific interventions, and findings highlight opportunities to advance the field’s understanding of engagement through multidimensional measurement in future studies.     

Relationship between the social and demographic characteristics of post-sentence offenders and the outcomes of forensic psychiatric referrals

Examined the relationship between the social and demographic characteristics of post-sentence offenders (N = 240) and outcome of outpatient forensic psychiatric referrals using multiple regression analysis. The referral process was divided into three stages: Decision to refer, compliance with referral, and outcome of referral, and the following research questions were explored: (1) whether there were differences between the social and demographic characteristics of offenders who were referred by court order of the sentencing judge and those referred by their probation officer; (2) the the relationship between socioeconomic status and completion of referral; (3) the relationship between socioeconomic status and recommendation for further mental health services; and (4) the relationship between source of referral and recommendation for mental health services. Results suggest that the relationship between social and demographic variables and the offender's interaction with a forensic mental health system is markedly different from the voluntary clients and mental health resources studied in earlier research.     

A critical appraisal of 'evidence-based medicine' in allergy and asthma

 Clinical guidelines are 'systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances'. They may offer concise instructions on which diagnostic or screening tests to order, stipulate how medical services should be provided, how long patients should stay in hospital, or many other details relevant to clinical practice. This paper argues that guidelines should be simple, adapted to the clinical setting they inform and to treatment availability in their respective geographic context and that they should not be viewed as a yardstick but as support for physicians. The benefits of evidence-based-medicine (EBM), which defines the value of medical interventions in terms of empiric evidence from clinical trials, are growing in many contexts and are well described. Not sufficiently acknowledged, however, are the limits of EBM. A gap still exists between clinical research and clinical practice which should be better recognized and assessed.     

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.     

Postpartum psychiatric emergency visits: a nested case-control study

Mental health conditions are one of the most common reasons for postpartum emergency department (ED) visits. Characteristics of women using the ED and their mental health service use before presentation are unknown. We characterized all women in Ontario, Canada (2006–2012), who delivered a live born infant and had a psychiatric ED visit within 1 year postpartum (n?=?8728). We compared those whose ED visit was the first physician mental health contact since delivery to those who had accessed mental health services on specific indicators of marginalization hypothesized to be associated with lower likelihood of mental health contact prior to the ED visit. For 60.4 % of women, this was the first physician mental health contact since delivery. The majority were presenting with a mood or anxiety disorder, and only 13.6 % required hospital admission. These women were more likely to have material deprivation and residential instability than women with contact (Q5 vs. Q1 aORs 1.30, 95 % CI 1.12–1.50; 1.17, 95 % CI 1.01–1.36), to live in rural vs. urban areas (aOR 1.58, 95 % CI 1.38–1.80), and to be low vs. high income quintile (aOR 1.18, 95 % CI 1.01–1.38). The frequent use of ED services as the first point of contact for mental health concerns suggests that interventions to improve timely and equitable access to effective outpatient postpartum mental health care are needed. Marginalized women are at particularly high risk of not having accessed outpatient services prior to an ED visit, and therefore, future research and interventions will specifically need to consider the needs of this group.     

A psychosocial risk assessment model (PRAM) for use with pregnant and postpartum women in primary care settings

Recognition of high rates of mental health morbidity and mortality that affect women during the perinatal period has prompted the development of psychosocial risk assessment programs. Designed to identify women, at risk, during routine health checks and delivered by primary care health service providers, these fit within a primary prevention and early intervention strategic approach to the reduction of perinatal mental illness and reflect an integrated approach to perinatal health services delivery. This paper describes the development and use of the psychosocial risk assessment model (PRAM) at the Royal Hospital for Women in Sydney, Australia. Data is presented on 2,142 women who attended the Antenatal Midwives Clinic between 2002 and 2005. The PRAM guides primary care staff to quickly identify women experiencing emotional distress and/or psychosocial problems during pregnancy or postnatal checks. Measures used in pregnancy are the symptom-based Edinburgh Depression Scale and the psychosocial risk-based Antenatal Risk Questionnaire. In postnatal setting the Postnatal Risk Questionnaire is used. Scores can be used to compute a Psychosocial Risk Index (PRI) to guide individualized care planning, define needs for referral and classify groups for clinical and research purposes. Based on the PRI, among 2,142 women assessed in pregnancy 70.6% were classified as low/no risk (no interventions indicated currently), 24.1% as medium risk (in need of monitoring), and 5.3% as high risk (complex). The PRAM offers a conceptual framework, methods and measures for brief psychosocial assessment with clinical and research applications. Postpartum follow up studies of women assessed during pregnancy have commenced. Randomized controlled trials and cross-cultural studies are now indicated to strengthen the evidence base for the model.     

Future Directions for Dissemination and Implementation Science: Aligning Ecological Theory and Public Health to Close the Research to Practice Gap

Dissemination and implementation science (DI) has evolved as a major research model for children's mental health in response to a long-standing call to integrate science and practice and bridge the elusive research to practice gap. However, to address the complex and urgent needs of the most vulnerable children and families, future directions for DI require a new alignment of ecological theory and public health to provide effective, sustainable, and accessible mental health services. We present core principles of ecological theory to emphasize how contextual factors impact behavior and allow for the reciprocal impact individuals have on the settings they occupy, and an alignment of these principles with a public health model to ensure that services span the prevention to intervention continuum. We provide exemplars from our ongoing work in urban schools and a new direction for research to address the mental health needs of immigrant Latino families. Through these examples we illustrate how DI can expand its reach by embedding within natural settings to build on local capacity and indigenous resources, incorporating the local knowledge necessary to more substantively address long-standing mental health disparities. This paradigm shift for DI, away from an overemphasis on promoting program adoption, calls for fitting interventions within settings that matter most to children's healthy development and for utilizing and strengthening available community resources. In this way, we can meet the challenge of addressing our nation's mental health burden by supporting the needs and values of families and communities within their own unique social ecologies.     

Integrating Decision Making and Mental Health Interventions Research: Research Directions

The importance of incorporating patient and provider decision-making processes is in the forefront of the National Institute of Mental Health (NIMH) agenda for improving mental health interventions and services. Key concepts in patient decision making are highlighted within a simplified model of patient decision making that links patient-level/"micro" variables to services-level/"macro" variables via the decision-making process that is a target for interventions. The prospective agenda for incorporating decision-making concepts in mental health research includes (a) improved measures for characterizing decision-making processes that are matched to study populations, complexity, and types of decision making; (b) testing decision aids in effectiveness research for diverse populations and clinical settings; and (c) improving the understanding and incorporation of preference concepts in enhanced intervention designs.     

Understanding community psychosocial needs after disasters: implications for mental health services

The psychosocial impact of disasters has attracted increasing attention. There is little consensus, however, about what priorities should be pursued in relation to mental health interventions, with most controversy surrounding the relevance of traumatic stress to mental health. The present overview suggests that acute traumatic stress may be a normative response to life threat which tends to subside once conditions of safety are established. At the same time, there is a residual minority of survivors who will continue to experience chronic posttraumatic stress disorder (PTSD) and their needs can be easily overlooked. The ADAPT model offers an expanded perspective on the psychosocial systems undermined by disasters, encompassing threats to safety and security; interpersonal bonds; systems of justice; roles and identities; and institutions that promote meaning and coherence. Social reconstruction programs that are effective in repairing these systems maximize the capacity of communities and individuals to recover spontaneously from various forms of stress. Within that broad recovery context, clinical mental health services can focus specifically on those psychologically disturbed persons who are at greatest survival risk. Only a minority of persons with acute traumatic stress fall into that category, the remainder comprising those with severe behavioural disturbances arising from psychosis, organic brain disorders, severe mood disorders and epilepsy. Establishing mental health services that are community-based, family-focused and culturally sensitive in the post-emergency phase can create a model that helps shape future mental health policy for countries recovering from disaster.     

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.     

Developing Cultural Competency in Clinical Practice: Treatment Considerations for Chinese Cultural Groups in the United States

The incorporation of specific cultural beliefs and behaviors into standard clinical treatments is sorely needed to improve our ability to provide services to people from diverse settings. Findings from a critical review of empirical research provides the basis for the modification of an integrative model of differential treatment selection. The relative influence of cultural beliefs and behaviors on patient characteristics, relationship variables, and treatment context are discussed. This article suggests ways to include cultural considerations at various steps within the model. Specific concerns, such as immigration, culture change, and conceptualizations of mental health, are discussed for one cultural group, the Chinese in the United States. A series of clinical practice decisions are suggested to guide clinicians in their efforts to incorporate specific cultural beliefs, including an analysis of the match between cultures and an assessment of the client's perceived opportunity within the culture of settlement. Types of interventions are suggested based on these decisions. A case study of a short-term treatment of a Chinese woman provides an illustration of the ways in which strategies and techniques in the model are modified.     

Using process evaluation to describe a hospital-based clinic for children coping with medical stressors

OBJECTIVE: To use process evaluation methods to describe the development of a hospital-based mental health clinic for children facing medical stressors. METHODS: Over a 21-month time period, we collected data regarding presenting concern, service use, and referral source using hospital administrative, clinic intake, and clinical records for 356 children. RESULTS: Nearly 90% of the children were referred to the clinic from sources within the hospital. With the exception of single session interventions, there were no differences in average length of services according to presenting concern. Hospital pediatric specialists and psychology consultants were the primary referrers to the program. Pediatric specialists referred more often for procedural concerns and chronic illness than other hospital referrers. CONCLUSIONS: These findings support the feasibility and usefulness of a process evaluation approach in shaping clinical program directions, creating opportunities for collaboration with medical providers, and planning effectiveness research.     

Making the Translation from Research to Its Application: The Je Ne Sais Pas of Evidence-Based Practices

Moving evidence-based treatments into practice settings is an important new direction for the field of children's mental health., but is fraught with many unknowns. This commentary discusses scientific conundrums that surround that transportability of research-based interventions, including issues of definition (e.g., differences among treatments, preventive interventions, services); diagnostic reification and the absence of markers; the value and status of combination treatments (including pharmacologic) for conceptualizing the evidence base; and differences between evidence-based practices and evidence-based treatments. Suggestions are made for a disciplined approach to advancing a yoked research and policy agenda for children's mental health.     

Postpartum depression: what we know

Postpartum depression (PPD) is a serious mental health problem. It is prevalent, and offspring are at risk for disturbances in development. Major risk factors include past depression, stressful life events, poor marital relationship, and social support. Public health efforts to detect PPD have been increasing. Standard treatments (e.g., Interpersonal Psychotherapy) and more tailored treatments have been found effective for PPD. Prevention efforts have been less consistently successful. Future research should include studies of epidemiological risk factors and prevalence, interventions aimed at the parenting of PPD mothers, specific diathesis for a subset of PPD, effectiveness trials of psychological interventions, and prevention interventions aimed at addressing mental health issues in pregnant women. © 2009 Wiley Periodicals, Inc. J Clin Psychol 65:1–12, 2009.