Practical behavioral trials to advance evidence-based behavioral medicine

There is a well-documented gap between research and practice in many areas of behavioral medicine. This gap is due in part to limitations in the capacity of the research database to address questions that are of central concern to clinicians, administrative decision makers, and policymakers. Thus, there has been a call for "practical clinical trials" that compare clinically viable alternative interventions and assess multiple outcomes important for clinical and policy decisions in diverse patient populations and settings. Such trials offer great potential, and they raise interesting challenges regarding optimal research design and source of funding. We discuss issues related to practical clinical trials in behavioral medicine, propose a need for practical behavioral trials (PBTs), and describe design features that will facilitate clinical and policy decision making. This type of PBT can help to close the gap between research and practice and advance the field of evidence-based behavioral medicine. We discuss potential challenges and objections to PBTs and conclude by providing recommendations for the design, conduct, reporting, and review of practical trials.

Estimating variability in outcomes attributable to therapists: a naturalistic study of outcomes in managed care

To estimate the variability in outcomes attributable to therapists in clinical practice, the authors analyzed the outcomes of 6,146 patients seen by approximately 581 therapists in the context of managed care. For this analysis, the authors used multilevel statistical procedures, in which therapists were treated as a random factor. When the initial level of severity was taken into account, about 5% of the variation in outcomes was due to therapists. Patient age, gender, and diagnosis as well as therapist age, gender, experience, and professional degree accounted for little of the variability in outcomes among therapists. Whether or not patients were receiving psychotropic medication concurrently with psychotherapy did affect therapist variability. However, the patients of the more effective therapists received more benefit from medication than did the patients of less effective therapists.

Transforming systems of care: the American Association of Community Psychiatrists Guidelines for Recovery Oriented Services

Thinking about recovery has grown significantly over the last 70 years, and particularly in the past fifteen. Promotion of recovery has recently been recognized as an organizing principle for the transformation of behavioral health services. Recovery is a personal process of growth and change which typically embraces hope, autonomy and affiliation as elements of establishing satisfying and productive lives in spite of disabling conditions or experiences. Recovery oriented services replace paternalistic, illness oriented perspectives with collaborative, autonomy enhancing approaches and represent a major cultural shift in service delivery. Recovery oriented services replace the myth of chronicity and dependence with a message of individualism, empowerment and choice in the context of collaborative relationships with service providers. The American Association of Community Psychiatrists has developed Guidelines for Recovery Oriented Services to facilitate the transformation of services to this new paradigm. The guidelines are divided into three domains: administration, treatment, and supports, each consisting of several elements for which recovery enhancing characteristics are defined. Several example indicators are also provided for each element. This paper presents these guidelines and discusses their application.

The acceptability and effectiveness of patient-reported assessments and feedback in a managed behavioral healthcare setting

OBJECTIVE

To determine whether providing clinicians with the results of a patient-reported mental health assessment would have a significant impact on patients' mental health outcomes.

STUDY DESIGN

The study used a portion of the SCL-90 (Symptom Checklist-90) to track the perceived mental health of 1374 patients in a managed behavioral healthcare system over 6 weeks.

METHODS

Participants were randomized into a feedback group whose clinicians received clinical feedback reports at intake and at 6 weeks, and a control group whose clinicians received no report.

RESULTS

Patients in the feedback group achieved statistically significant improvement in clinical status relative to controls.

CONCLUSIONS

Overall, the study suggests that patient-reported mental health assessments have the potential both to become acceptable to clinicians and to improve the effectiveness of clinical care.

The fundamentals of workforce competency: implications for behavioral health

Increasing attention is being directed to the competency of those who deliver healthcare in the United States. In behavioral health, there is growing recognition of the need to define, teach, and assess essential competencies. Since attention to this issue in behavioral health is relatively recent, there is much to be gained by learning from the principles, definitions, and conceptual models of competency that have been developed in other fields. This article outlines the forces that drive the current focus on competency of the healthcare workforce. Relevant history, principles, definitions, and models that have evolved through research and application in business and industry are reviewed. From this analysis, recommendations are offered to guide future work on competencies in behavioral health.

Workforce competencies in behavioral health: an overview

Competency-based training approaches are being used more in healthcare to guide curriculum content and ensure accountability and outcomes in the educational process. This article provides an overview of the state of competency development in the field of behavioral health. Specifically, it identifies the groups and organizations that have conducted and supported this work, summarizes their progress in defining and assessing competencies, and discusses both the obstacles and future directions for such initiatives. A major purpose of this article is to provide a compendium of current competency efforts so that these might inform and enhance ongoing competency development in the varied behavioral health disciplines and specialties. These varied resources may also be useful in identifying the core competencies that are common to the multiple disciplines and specialties.

Teaching Behavioral Pain Management to Healthcare Professionals: A Systematic Review of Research in Training Programs

Pain is a common and potentially debilitating condition. Whereas there is vast literature on developmentally appropriate behavioral techniques for pain management, results of curriculum evaluations and knowledge surveys reveal a dearth of awareness of these strategies in healthcare professionals. As a result, the development and evaluation of pain management training programs are important endeavors. Results of studies evaluating such programs are promising and suggest that training might be an effective means of impacting healthcare professionals' knowledge, attitudes, and even patient care. These results must be interpreted with caution, however, because the literature contains several conceptual and methodologic limitations. These limitations, in combination with the wide diversity in program components, format of delivery, and research methods, preclude definitive conclusions on the most practical and effective means to provide training. To address this question, further systematic work on the development and evaluation of pain management training programs is warranted.

PERSPECTIVE

To address the problems of dissemination of behavioral pain management techniques, the development and evaluation of pain management training programs are important endeavors. The current article presents a systematic review of studies evaluating such programs and provides recommendations for future systematic work in this area.

Curriculum resources for training Direct care providers in public Sector mental health

Direct care personnel who do not have graduate-level professional degrees provide a substantial amount of client care in mental health organizations across the nation. Training for them is minimal in many settings. This shortcoming may negatively affect client care, staff recruitment and retention, and the effective use of scarce resources. In this paper, we identify and review curriculum resources available to mental health organizations interested in implementing or enhancing training programs for direct care personnel. These include two relevant competency sets and six portable training curricula, as well as information on how to access these resources.

Strategies for Developing Competency Models

There is an emerging trend within healthcare to introduce competency-based approaches in the training, assessment, and development of the workforce. The trend is evident in various disciplines and specialty areas within the field of behavioral health. This article is designed to inform those efforts by presenting a step-by-step process for developing a competency model. An introductory overview of competencies, competency models, and the legal implications of competency development is followed by a description of the seven steps involved in creating a competency model for a specific function, role, or position. This modeling process is drawn from advanced work on competencies in business and industry.

Report of Recommendations: The Annapolis Coalition Conference on Behavioral Health Work Force Competencies

In May 2004, the Annapolis Coalition on Behavioral Health Workforce Education convened a national meeting on the identification and assessment of competencies. The Conference on Behavioral Health Workforce Competencies brought leading consumer and family advocates together with other experts on competencies from diverse disciplines and specialties in the fields of both mental health care and substance use disorders treatment. Aided by experts on competency development in business and medicine, conference participants have generated 10 consensus recommendations to guide the future development of workforce competencies in behavioral health. This article outlines those recommendations. A collaborative effort to identify a set of core or common competencies is envisioned as a key strategy for advancing behavioral health education, training, and other workforce development initiatives.

Best practices for assessing competence and performance of the behavioral Health workforce

The need for mechanisms to assess the competence and performance of the behavioral health workforce has received increasing attention. This article reviews strategies used in general medicine and other disciplines for assessing trainees and practitioners. The possibilities and limitations of various approaches are reviewed, and the implications for behavioral health are addressed. A conceptual model of competence is presented, and practical applications of this model are reviewed. Finally, guidelines are proposed for building competency assessment protocols for behavioral health.

A national sample of IAPSRS members' responses to the psychiatric rehabilitation beliefs, goals, and practices scale

This study reports on the convergent-discriminant validity of the Psychiatric Rehabilitation Beliefs, Goals, and Practices Scale (PRBGP) which purports to measure practitioners' knowledge of the current consensus in psychiatric rehabilitation. The sample comprised 478 IAPSRS members who represented practitioners from 39 states. The study found that the PRBGP variance among this sample was primarily associated with the number of 15 leading contributors to the psychiatric rehabilitation literature that these practitioners claimed to have read when education, discipline, role, experience, and agency area were controlled. Experience in the behavioral health field and the administrator role were also significantly related to the PRBGP, but these relationships may have also been a function of informational factors associated with IAPSRS membership. For a combined sample (n = 757), it was also found that the PRBGP is primarily related to the number of leading authors that these practitioners read. The PRGBP appears to measure knowledge of the current consensus on beliefs, goals, and practices in psychiatric rehabilitation, and is not a measure of these other responder characteristics.

Evaluating cultural competence among behavioral health professionals

Persistent racial and ethnic disparities in access and utilization of behavioral health services have highlighted the need for cultural competence among providers. In response, many agencies are now implementing education and training programs to ensure that behavioral health professionals improve their skills when serving diverse ethnic, racial, and cultural populations. The evaluation of these trainings is vital to ensure that they both improve the cultural competence of providers and promote recovery among persons with severe mental illnesses. This paper discusses the philosophical and practical issues related to measuring cultural competence, based on the evaluation of statewide cultural competence trainings for behavioral health professionals. The evaluation process illustrates the challenges of operationalizing cultural competence, balancing the needs of program implementers and evaluators, and developing a robust and feasible evaluation design, which assesses outcomes both for persons in recovery and providers.

fMRI biomarker of early neuronal dysfunction in presymptomatic Huntington's Disease

BACKGROUND AND PURPOSE

Functional MR imaging (fMRI) has been used to probe basal ganglia function in people with presymptomatic Huntington's disease (pre-HD). A previous fMRI study in healthy individuals demonstrated activation of the basal ganglia during a time-discrimination task. The current study was designed to examine the relative sensitivity of fMRI compared with that of behavioral testing and morphometric measurements in detecting early neurodegenerative changes related to Huntington's disease (HD).

METHODS

Pre-HD participants were assigned to two groups based on estimated years to diagnosis of manifest disease: close <12 years and far >or=12 years. Age at disease onset was estimated using a regression equation based on the number of trinucleotide CAG repeats. The time-discrimination task required participants to determine whether a specified interval was shorter or longer than a standard interval of 1200 milliseconds.

RESULTS

Participants in the close group performed more poorly on the time-task discrimination than did control subjects; however, no differences were observed between far participants and control subjects. Similarly, close participants had reduced bilateral caudate volume relative to that of control subjects, whereas far participants did not. On functional imaging, close participants had significantly less activation in subcortical regions (caudate, thalamus) than control subjects; far participants had an intermediate degree of activation. In contrast, far participants had hyperactivation in medial hemispheric structures (anterior cingulate, pre-supplementary motor area) relative to close and control subjects.

CONCLUSION

Hyperactivation of medial prefrontal regions compensated for reduced subcortical participation during time discrimination in pre-HD. This pattern of brain activation may represent an early neurobiologic marker of neuronal dysfunction.

Using the Quality Improvement Committee to Establish Accountability and Yield Results

Healthcare organizations can respond effectively and efficiently to the needs of consumers and the demands of customers, accreditation agencies, and regulators by implementing a comprehensive quality improvement (QI) program. Using committees with cross-departmental representation, the QI program can facilitate review, analysis, prioritization of opportunities for improvement, and the facilitation of positive change. This article provides an example of how a managed behavioral healthcare organization responded to consumer needs and marketplace demands by using such an approach.

Effect sizes and statistical testing in the determination of clinical significance in behavioral medicine research

BACKGROUND

The interpretation of clinical significance continues to be an obstacle for researchers in behavioral medicine.

PURPOSE

To review selected behavioral medicine research to critically examine the perception among investigators that behavioral effects on health are small based on common metrics of clinical significance.

METHODS

Using quantitative findings from recent behavioral medicine research in medical and psychiatric journals, we explored results in terms of several statistical metrics to assess potential clinical significance: r coefficients, risk ratios, risk difference measures, and attributable risk.

RESULTS

Translated into r coefficients, even established health predictors such as smoking, obesity, and fitness had only modest effects (rs =.03-.22), and the range of effect sizes were comparable with those based on psychological predictors including depression and stress-reactivity (rs =.06-.22). In contrast, effects for both classes of predictors were suggestive of clinical significance based on public health statistics.

CONCLUSIONS

Our choice of statistics for defining "small" and "large" effect sizes affects the perceived importance of behavioral health findings. In the assessment of health outcomes with low incidence rates, effects expressed as correlations using even the most robust predictors will often appear small. In these instances, we challenge researchers to move beyond conventional data analysis approaches and to expand their clinical interpretation efforts by employing additional statistical methods favored in medicine and public health.