The dissemination and implementation of psychological treatments: problems and solutions

Clinical Experiences Using Cognitive-Behavioral Therapy for Eating Disorders

Data suggests that despite the availability of evidence-based psychological treatments for eating disorders (EDs), techniques from these therapies may be less frequently used within real-life clinical practice. The aim of this study was to provide the opportunity for clinicians to give feedback on their experiences treating EDs using cognitive-behavioral therapy (CBT) through reporting on use of CBT techniques and barriers to treatment implementation in naturalistic settings. Clinicians (N = 126) who self-identified as using CBT for EDs reported demographic information, frequency/usefulness of empirically supported treatment techniques, problems/limitations of CBT, and barriers faced while implementing CBT. The most frequently used technique reported by clinicians was psychoeducation, and the least frequently used technique was use of surveys to address mind reading. Patients' unwillingness to follow a meal plan/nutritional guide was rated as the most impactful barrier, alongside ED severity. Of the problems/limitations of CBT, too little guidance on treating co-occurring symptoms was rated as the most impactful. This study provided a mechanism for clinicians to share their experiences using CBT for EDs in real-world settings. Overall, results regarding frequency of use and usefulness of techniques indicate a high level of endorsement. Moreover, the most frequently endorsed barriers to/limitations of CBT related to lack of guidance on treating complex ED presentations. Future research should explore ways to treat cases that go beyond the prototypical ED case and explore ways to adapt CBT to meet the needs of naturalistic treatment settings.

Development and usability testing of an online platform for provider training and implementation of cognitive-behavioral therapy guided self-help for eating disorders

Background

Most individuals with eating disorders (EDs) do not receive treatment, and those who do receive care typically do not receive evidence-based treatment, partly due to lack of accessible provider training. This study developed a novel "all-in-one" online platform for disseminating training for mental health providers in cognitive-behavioral therapy guided self-help (CBTgsh) for EDs and supporting its implementation. The aim of the study was to obtain usability data from the online platform prior to evaluating its effects on provider training outcomes and patient ED symptom outcomes in an open pilot trial.

Methods

Nine mental health provider participants (n = 4 in Cycle 1; n = 5 in Cycle 2) and 9 patient participants (n = 4 in Cycle 1; n = 5 in Cycle 2) were enrolled over two cycles of usability testing. In Cycle 1, we recruited providers and patients separately to complete brief platform testing sessions. In Cycle 2, we recruited provider-patient dyads; providers completed training using the platform and subsequently delivered CBTgsh to a patient for three weeks. Usability was assessed using the System Usability Scale (SUS), the Usefulness, Satisfaction, and Ease of Use Questionnaire (USE), and semi-structured interviews.

Results

Interview feedback converged on two themes for providers (applicability of program for real-world use, platform structure and function) and two themes for patients (barriers and facilitators to engagement, perceived treatment effects). SUS and USE scores were in the "average" to "good" ranges across cycles.

Conclusions

Findings from this study demonstrate preliminary feasibility and acceptability of the online platform. Data collected in this study will inform further refinements to the online platform. The platform's effects on provider training outcomes and patient ED symptom outcomes will be evaluated in an open pilot trial. Given the wide treatment gap for EDs and barriers to dissemination and implementation of evidence-based treatments, the online platform represents a scalable solution that could improve access to evidence-based care for EDs.

Effects of Shared Decision Making Model-Based Guided Self-Help Program on Emotional Eating and Uncontrolled Eating Behavior in Individuals with a Severe Mental Disorder: A Randomized Controlled Trial

PURPOSE

The study was aimed at determining the effectiveness of the Shared Decision Making Model-based Guided Self-Help Program (SDM-GSH) on emotional eating behavior and uncontrolled eating behavior in individuals with a severe mental disorder.

METHOD

This randomized controlled experimental study was conducted in the Community Mental Health Center of a university hospital between September 2020 and November 2022. The sample of the study consisted of 64 participants. Of them, 33 were in the Experimental Group and 31 were in the control group. To collect the study data, the Patient Information Form, Emotional Eater Questionnaire, and Three-Factor Eating Questionnaire were administered. The participants in the Experimental Group took part in the SDM-GSH. The study data were collected from the participants in the Experimental and Control Groups before, right after and 6 months after the intervention.

RESULTS

The comparison of the BMI values of the participants with a severe mental disorder who took part in the SDM-GSH demonstrated that their pre-intervention BMI values significantly decreased at the measurements preformed right after and 6 months after the intervention (p < 0.05). The mean emotional eating (λ = 0.189, η2 = 0.811) and uncontrolled eating (λ = 0.218, η2 = 0.782) scores obtained by the participants in the Experimental Group before the intervention significantly decreased at the measurements preformed right after and 6 months after the intervention (p < 0.05).

CONCLUSION

Based on the results of our study, it is concluded that the SDM-GSH positively affected the BMI values, emotional eating behaviors and uncontrolled eating behaviors of the participants with a severe mental disorder.

Multifamily therapy for adolescent eating disorders: a study of the change in eating disorder symptoms from start of treatment to follow-up

BACKGROUND

This study aimed to evaluate multifamily therapy (MFT) for adolescents with eating disorders (EDs) in a clinical setting, by presenting the outcome of families participating in this treatment at a specialist ED service. MFT was an adjunct to treatment at local mental health services. In particular, the study aimed to present the change in eating disorder symptoms and psychological distress from before to after treatment and at a 6 months follow-up.

METHODS

Participants were 207 adolescents receiving outpatient MFT (10 or 5 months) at Oslo University Hospital in Norway between 2009 and 2022. Adolescents had heterogeneous ED presentations, with a preponderance of anorexia nervosa (AN) and atypical AN. All participants completed pre- and post-treatment questionnaires [The eating disorder examination questionnaire (EDE-Q) and the strengths and difficulties questionnaire (SDQ)]. 142 adolescents additionally completed the same questionnaires at 6 months follow-up. Weight and height were measured at all time points.

RESULTS

Linear mixed model analyses showed that from start of treatment to follow-up, there was a significant increase in BMI percentile (p < 0.001) and a significant decrease in EDE-Q global score (p < 0.001) and SDQ total score (p < 0.001).

CONCLUSIONS

The study shows that adolescents with an eating disorder who received adjunct outpatient MFT in a real world clinical setting, experienced reductions in ED symptoms comparable to that found in a randomized controlled trial.

TRIAL REGISTRATION

The data used in this study was collected as part of routine clinical procedures for quality assurance and trial registration is therefore not required.

A Web-Based Therapist Training Tutorial on Prolonged Grief Disorder Therapy: Pre-Post Assessment Study

BACKGROUND

Prolonged grief disorder (PGD) is a newly recognized mental disorder characterized by pervasive intense grief that persists longer than cultural or social expectations and interferes with functioning. The COVID-19 epidemic has resulted in increased rates of PGD, and few clinicians feel confident in treating this condition. PGD therapy (PGDT) is a simple, short-term, and evidence-based treatment developed in tandem with the validation of the PGD diagnosis. To facilitate the dissemination of PGDT training, we developed a web-based therapist tutorial that includes didactic training on PGDT concepts and principles as well as web-based multimedia patient scenarios and examples of clinical implementation of PGDT.

OBJECTIVE

We aimed to evaluate user satisfaction with the tutorial and whether the tutorial increased trainees' knowledge of PGDT principles and procedures. Moreover, we included a small number of pilot questions to evaluate the PGDT-related clinical skills.

METHODS

This study evaluated tutorial learning using a pre- and poststudy design. Participants were recruited from professional organization mailing lists, announcements to graduates of the Columbia School of Social Work, and through word of mouth. After signing consent, participants completed a brief demographic survey, a 55-item multiple-choice prestudy test on the concepts and principles of PGD and PGDT covered in the tutorial, and a 4-item pilot web-based prestudy test to gauge PGD clinical implementation skills. The link to the course content was then activated, and participants were given 8 weeks to complete the 11-module tutorial containing information, web-based exercises, simulated patient and video examples, and self-tests.

RESULTS

Overall, 406 clinicians signed consent, and 236 (58.1%) started the tutorial. Of these, 83.1% (196/236) completed all 11 modules. Trainee scores on our PDGT assessment improved substantially from pretraining to the postmodule assessment, with the total number of correct answers increasing from a mean of 29 (SD 5.5; 52.7% correct) to 36.7 (SD 5.2; 66.7% correct; t₁₉₅=18.93; P<.001). In addition, the trainee's implementation scores on 4 clinical vignettes increased from 2.6 (SD 0.7) correct out of 4 to 3.1 (SD 0.4) out of 4 (t₁₈₈=7.02; P<.001). Effect sizes (Cohen d) were 1.44 (95% CI 1.23-1.65) for PDGT assessment and 1.06 (95% CI 0.84-1.29) for implementation. Trainees found the tutorial interesting, enjoyable, clearly presented, and useful for professional development. They endorsed a mean score of 3.7 (SD 0.47) on a 1 to 4 scale of agreement with recommending the course to others and feeling satisfied with the tutorial, and a mean of 3.3 (SD 0.57) with feeling able to apply the skills with clients.

CONCLUSIONS

This pilot study provides support for the usefulness of this web-based training for teaching clinicians how to administer PGDT. The addition of patient scenarios for clinical implementation strategies holds promise for increasing the effectiveness of PGDT training and other evidence-based treatments.

TRIAL REGISTRATION

ClinicalTrials.gov NCT05121792; https://www.clinicaltrials.gov/ct2/show/NCT05121792.

A pilot randomized controlled trial of a cognitive-behavioral therapy guided self-help mobile app for the post-acute treatment of anorexia nervosa: A registered report

INTRODUCTION

Relapse following acute treatment for anorexia nervosa (AN) is common. Evidence suggests cognitive-behavioral therapy (CBT) may be useful in the post-acute period, but few patients have access to trained providers. mHealth technologies have potential to increase access to high-quality care for AN, including in the post-acute period. The aim of this study is to estimate the preliminary feasibility and effectiveness of a CBT-based mobile intervention plus treatment as usual (TAU), offered with and without an accompanying social networking feature.

METHOD

In the current pilot randomized controlled trial, women with AN who have been discharged from acute treatment in the past 2 months (N = 90) will be randomly assigned to a CBT-based mobile intervention plus treatment as usual (TAU), a CBT-based mobile intervention including social networking plus TAU, or TAU alone. We will examine feasibility, acceptability, and preliminary effectiveness of the three conditions in terms of reducing eating disorder psychopathology, reducing frequency of eating disorder behaviors, achieving weight maintenance, reducing depression and suicidal ideation, and reducing clinical impairment. We will examine rehospitalization and full recovery rates in an exploratory fashion. We will also examine whether the mobile intervention and social networking feature change the proposed targets and whether changes in targets are associated with benefit, as well as conduct exploratory analyses to identify within-mobile intervention predictors and moderators of outcome.

DISCUSSION

Ultimately, this research may lead to increased access to evidence-based treatment for individuals with AN and prevention of the extreme negative consequences that can result from this serious disorder.

PUBLIC SIGNIFICANCE

Relapse after acute treatment for anorexia nervosa is common, and few patients have access to trained providers to support them following acute care. This study will pilot a coached mobile app, including a social networking component, for this population. If ultimately successful, our approach could greatly increase access to evidence-based treatment for individuals with anorexia nervosa and ultimately prevent the extreme negative consequences that can result from this serious disorder.

Developing, Deploying, and Evaluating Digital Mental Health Interventions in Spaces of Online Help- and Information-Seeking

The internet is frequently the first point of contact for people seeking support for their mental health symptoms. Digital interventions designed to be deployed through the internet have significant promise to reach diverse populations who may not have access to, or are not yet engaged in, treatment and deliver evidence-based resources to address symptoms. The liminal nature of online interactions requires designing to prioritize needs detection, intervention potency, and efficiency. Real-world implementation, data privacy and safety are equally important and can involve transparent partnerships with stakeholders in industry and non-profit organizations. This commentary highlights challenges and opportunities for research in this space, grounded in learnings from multiple research projects and teams aligned with this effort.

Feasibility of guided internet-based cognitive behavioral therapy for patients with anorexia nervosa

OBJECTIVE

The objective of the present study was to investigate the feasibility of guided internet cognitive behavioral therapy (ICBT) for anorexia nervosa.

METHODS

We conducted a prospective single-arm study between January 2020 and March 2021. The intervention was built using videos, web programs, and chat tools. The intervention program was largely based on metacognitive training. Participants performed the self-help program once a week for 12 consecutive weeks. The primary outcome was the global Eating Disorder Examination Questionnaire (EDE-Q) score. Secondary outcomes included clinical symptoms of eating disorders, metacognitive function, body mass index, depression, and generalized anxiety. The main statistical analysis examined whether the EDE-Q score and other outcomes at the end of the intervention differed from the baseline.

RESULTS

Fourteen participants underwent the trial treatment, and 13 completed the intervention. There was a significant reduction in the global EDE-Q score from 3.48 (SD = 1.4) to 2.54 (SD = 1.5, p = 0.02, Cohen's d = 0.75) from baseline to post-intervention. Some EDE-Q subscales and body checking questionnaire scale demonstrated statistically significant improvements, with moderate to large effect sizes. Although there was no significant improvement in body mass index, metacognitive function, or depressive symptoms, there was a significant improvement in the severity of generalized anxiety (M = -4.0, p = 0.01, Cohen's d = 0.95). No adverse events were observed.

DISCUSSION

Our findings suggest that guided ICBT for anorexia nervosa is well accepted by female patients and practical as a telemedicine approach that improves symptoms. In the future, tightly controlled randomized controlled trials should be conducted for efficacy verification.

Maintenance of Training Effects of Two Models for Implementing Evidence-Based Psychological Treatment

OBJECTIVE

The authors compared maintenance of training outcomes for two approaches to training college therapists in interpersonal psychotherapy (IPT): train the trainer versus expert training.

METHODS

A cluster-randomized trial was conducted in 24 college counseling centers. Therapists were recruited from enrolled centers, and the therapists enrolled students with depression and eating disorder symptoms. The therapists (N=184) provided data during baseline, posttraining (during the 12 months of expert consultation offered to the expert training group), and maintenance (approximately 7 months after the expert consultation ended). Outcomes were therapist fidelity (i.e., adherence and competence) and IPT knowledge.

RESULTS

Both groups showed within-group improvement from baseline to the maintenance period for adherence, competence, and IPT knowledge; however, the train-the-trainer group had greater improvement over time in adherence and competence.

CONCLUSIONS

Given that the effects of the train-the-trainer approach were better maintained, and this model's potential to train more therapists over time, the train-the-trainer approach may help increase dissemination of evidence-based treatments such as IPT.

From research to practice: a model for clinical implementation of evidence-based outpatient interventions for eating disorders

BACKGROUND

A question frequently raised in the field is whether evidence-based interventions have adequate translational capacity for delivery in real-world settings where patients are presumed to be more complex, clinicians less specialized, and multidisciplinary teams less coordinated. The dual purpose of this article is to (a) outline a model for implementing evidence-driven, outpatient treatments for eating disorders in a non-academic clinical setting, and (b) report indicators of feasibility and quality of care.

MAIN BODY

Since our inception (2015), we have completed nearly 1000 phone intakes, with first-quarter 2021 data suggesting an increase in the context of COVID-19. Our caseload for the practice currently consists of approximately 200 active patients ranging from 6 to 66 years of age. While the center serves a transdiagnostic and trans-developmental eating disorder population, modal concerns for which we receive inquiries are Anorexia Nervosa and Avoidant Restrictive Food Intake Disorder, with the most common age range for prospective patients spanning childhood through late adolescence/emerging adulthood; correspondingly, the modal intervention employed is Family-based treatment. Our team for each case consists, at a minimum, of a primary internal therapist and a physician external to the center.

SHORT CONCLUSION

We will describe our processes of recruiting, training and coordinating team members, of ensuring ongoing fidelity to evidence-based interventions, and of training the next generation of clinicians. Future research will focus on a formal assessment of patient outcomes, with comparison to benchmark outcomes from randomized controlled trials.

Barriers to Building More Effective Treatments: Negative Interactions Amongst Smoking Intervention Components

Meaningfully improved mental and behavioral health treatment is an unrealized dream. Across three factorial experiments, inferential tests in prior studies showed a pattern of negative interactions suggesting that better clinical outcomes are obtained when participants receive fewer rather than more intervention components. Further, relatively few significant main effects were found in these experiments. Modeling suggested that negative interactions amongst components may account for these patterns. This paper evaluates factors that may contribute to such declining benefit: increased attentional or effort burden; components that produce their effects via the same capacity limited mechanisms, making their effects subadditive; and a tipping point phenomenon in which those near a hypothesized "tipping point" for change will benefit markedly from weak intervention while those far from the tipping point will benefit little from even strong intervention. New research should explore factors that cause negative interactions amongst components and constrain the development of more effective treatments.

From research to clinical practice: a systematic review of the implementation of psychological interventions for chronic headache in adults

BACKGROUND

Psychological interventions have been proved to be effective in chronic headache (CH) in adults. Nevertheless, no data exist about their actual implementation into standard clinical settings. We aimed at critically depicting the current application of psychological interventions for CH into standard care exploring barriers and facilitators to their implementation. Secondarily, main outcomes of the most recent psychological interventions for CH in adults have been summarized.

METHODS

We conducted a systematic review through PubMed and PsycINFO in the time range 2008-2018. A quality analysis according to the QATSDD tool and a narrative synthesis were performed. We integrated results by: contacting the corresponding author of each paper; exploring the website of the clinical centers cited in the papers.

RESULTS

Of the 938 identified studies, 28 papers were selected, whose quality largely varied with an average %QATSDD quality score of 64.88%. Interventions included CBT (42.85%), multi-disciplinary treatments (22.43%), relaxation training (17.86%), biofeedback (7.14%), or other interventions (10.72%). Treatments duration (1 day-9 months) and intensity varied, with a prevalence of individual-basis implementation. The majority of the studies focused on all primary headaches; 4 studies focused on medication-overuse headache. Most of the studies suggest interventions as effective, with the reduction in frequency of attacks as the most reported outcome (46.43%). Studies were distributed in different countries, with a prevalent and balanced distribution in USA and Europe. Ten researches (35.71%) were performed in academic contexts, 11 (39.28%) in clinical settings, 7 (25%) in pain/headache centres. Interventions providers were professionals with certified experience. Most of the studies were funded with private or public funding. Two contacted authors answered to our e-mail survey, with only one intervention implemented in the routine clinical practice. Only in three out of the 16 available websites a reference to the implementation into the clinical setting was reported.

CONCLUSION

Analysis of contextual barriers/facilitators and cost-effectiveness should be included in future studies, and contents regarding dissemination/implementation of interventions should be incorporated in the professional training of clinical scientists. This can help in filling the gap between the existing published research and treatments actually offered to people with CH.

Training Models for Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers

IMPORTANCE

Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed.

OBJECTIVE

To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored.

DESIGN, SETTING, AND PARTICIPANTS

This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists.

INTERVENTIONS

Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members.

MAIN OUTCOMES AND MEASURES

The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome.

RESULT

A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P < .001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P < .001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P < .001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P = .03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P = .005; expert, 0.69 [95% CI, 0.38-1.01]; P < .001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P = .048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P = .048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P = .03).

CONCLUSIONS AND RELEVANCE

Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02079142.

Positive Aging: The Impact of a Community Wellbeing and Resilience Program

Objectives: To test the effect of a community wellbeing intervention, delivered by community partners, on the wellbeing, resilience, optimism, and social connection of older adults in the general population (Study 1) and older adult carers (Study 2), a population at risk for low wellbeing. Methods: Participants self-selected to take part in an 8-week multi-component wellbeing and resilience program consisting of weekly training sessions, and optional mentoring/peer support. Program participants and a natural control group were compared, post-intervention, on all outcomes of interest. Results: Intervention participants (Study 1) reported significantly lower scores of social isolation, but no significant difference in wellbeing, optimism, or resilience. Intervention participants (Study 2) showed significantly higher scores on all measured outcomes except social isolation. Conclusion: These studies point towards the potential benefits of wellbeing interventions for older adult from the general population and older adult carers, when delivered by community partners. Clinical implications: Early interventions promoting mental health may contribute to reducing the burden of mental health conditions on individuals and the health care system. Studies with more rigorous designs and extended follow-up measurements are required to consolidate these positive initial findings.

A protocol for designing online training to support the implementation of community-based interventions

Training program implementers through online methods represents a way of facilitating the widespread implementation of community-based interventions that is more financially and logistically feasible than traditional in-person training methods. However, there are few evidence-informed protocols or models that can guide the development of online training content in a way that is consistent with instructional best practices. This paper presents an evidence-informed protocol for developing a training website, or online training platform, to support the implementation of community-based interventions at scale, which was informed by a critical analysis of the instructional design literature and our experiences developing an online training platform for the HealtheStepsTM Lifestyle Prescription Program. The protocol is an operationalization of the ADDIE model of instructional design, and details the analysis, design, development, implementation, and evaluation stages of the process. Examples from the HealtheStepsTM program are used to illustrate the use of the protocol in practice. The protocol emphasizes the need for rigorous analysis of the target audience and a multidisciplinary literature base drawing from instructional design and implementation science. It can be used by researchers to guide the development of online training platforms to support the widespread implementation of evidence-based health interventions, thus increasing their public health impact.

Therapist adherence and therapeutic alliance in individual cognitive-behavioural therapy for adolescent binge-eating disorder

To evaluate psychological treatments for adolescent binge-eating disorder (BED), reliable information on therapeutic process factors is needed. This study examines therapist adherence and therapeutic alliance and their associations in cognitive-behavioural therapy (CBT) for adolescents with BED. In a randomised-controlled efficacy trial, adherence and alliance were objectively determined based on 247 audio-taped CBT sessions from a sample of N = 64 adolescents with BED. Variability of adherence and alliance, explained by treatment module, patient, and therapist were examined using multilevel modeling. Although adherence and alliance were excellent and unaffected by treatment module and therapist, there was significant between-patient variability for both concepts. Adherence was negatively associated with patient's treatment expectation. Alliance was negatively associated with the number of loss of control eating episodes and positively associated with adherence. Excellent adherence supported the internal validity of CBT for adolescent BED. Associations between process factors and patient characteristics demand adequate supervision in CBT.

Training models for implementing evidence-based psychological treatment for college mental health: A cluster randomized trial study protocol

Mental disorders often emerge in adolescence and young adulthood, and these disorders can have lasting effects on students' health, social functioning, and education. Although evidence-based treatments have been established for many mental disorders, few community therapists use such treatments. What is needed is a practical, economically feasible means of training clinicians to implement evidence-based treatments suitable for widespread use. This cluster randomized trial will randomize 26 college counseling centers to one of two implementation strategies for training counselors to use interpersonal psychotherapy (IPT), an evidence-based treatment for depression and eating disorders: 1) an external expert consultation model comprising a workshop, therapy manual, and expert follow-up consultation (n = 13); or 2) a train-the-trainer model in which a staff member from the counseling center is coached to train other staff members to implement IPT (n = 13). The primary outcome is therapist adherence to IPT, with secondary outcomes of therapist competence in IPT and client outcomes for depression and eating disorders. Therapist and organizational characteristics will be explored as potential moderators and mediators of implementation outcomes. Implementation costs for each of the training methods will also be assessed. The present study involves partnering with college counseling centers to determine the most effective method to implement IPT for depression and eating disorders in these settings. The results of this study will inform future large-scale dissemination of clinical interventions to mental health service providers by providing evidence for the selection of training methods when an agency chooses to adopt new interventions.

Increasing the Availability of Psychological Treatments: A Multinational Study of a Scalable Method for Training Therapists

BACKGROUND

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. A highly scalable form of Web-centered therapist training, undertaken without external support, has recently been shown to have promise in promoting therapist competence.

OBJECTIVE

The aim of this study was to conduct an evaluation of the acceptability and effectiveness of a scalable independent form of Web-centered training in a multinational sample of therapists and investigate the characteristics of those most likely to benefit.

METHODS

A cohort of eligible therapists was recruited internationally and offered access to Web-centered training in enhanced cognitive behavioral therapy, a multicomponent, evidence-based, psychological treatment for any form of eating disorder. No external support was provided during training. Therapist competence was assessed using a validated competence measure before training and after 20 weeks.

RESULTS

A total of 806 therapists from 33 different countries expressed interest in the study, and 765 (94.9%) completed a pretraining assessment. The median number of training modules completed was 15 out of a possible 18 (interquartile range, IQR: 4-18), and 87.9% (531/604) reported that they treated at least one patient during training as recommended. Median pretraining competence score was 7 (IQR: 5-10, range: 0-19; N=765), and following training, it was 12 (IQR: 9-15, range: 0-20; N=577). The expected change in competence scores from pretraining to posttraining was 3.5 (95% CI 3.1-3.8; P<.001). After training, 52% (300/574) of therapists with complete competence data met or exceeded the competence threshold, and 45% (95% CI 41-50) of those who had not met this threshold before training did so after training. Compliance with training predicted both an increase in competence scores and meeting or exceeding the competence threshold. Expected change in competence score increased for each extra training module completed (0.19, 95% CI 0.13-0.25), and those who treated a suitable patient during training had an expected change in competence score 1.2 (95% CI 0.4-2.1) points higher than those who did not. Similarly, there was an association between meeting the competence threshold after training and the number of modules completed (odds ratio, OR=1.11, 95% CI 1.07-1.15), and treating at least one patient during training was associated with competence after training (OR=2.2, 95% CI 1.2-4.1).

CONCLUSIONS

Independent Web-centered training can successfully train large numbers of therapists dispersed across a wide geographical area. This finding is of importance because the availability of a highly scalable method of training potentially increases the number of people who might receive effective psychological treatments.

A Review of Studies on the System-Wide Implementation of Evidence-Based Psychotherapies for Posttraumatic Stress Disorder in the Veterans Health Administration

Since 2006, the Veterans Health Administration (VHA) has instituted policy changes and training programs to support system-wide implementation of two evidence-based psychotherapies (EBPs) for posttraumatic stress disorder (PTSD). To assess lessons learned from this unprecedented effort, we used PubMed and the PILOTS databases and networking with researchers to identify 32 reports on contextual influences on implementation or sustainment of EBPs for PTSD in VHA settings. Findings were initially organized using the exploration, planning, implementation, and sustainment framework (EPIS; Aarons et al. in Adm Policy Ment Health Health Serv Res 38:4-23, 2011). Results that could not be adequately captured within the EPIS framework, such as implementation outcomes and adopter beliefs about the innovation, were coded using constructs from the reach, effectiveness, adoption, implementation, maintenance (RE-AIM) framework (Glasgow et al. in Am J Public Health 89:1322-1327, 1999) and Consolidated Framework for Implementation Research (CFIR; Damschroder et al. in Implement Sci 4(1):50, 2009). We highlight key areas of progress in implementation, identify continuing challenges and research questions, and discuss implications for future efforts to promote EBPs in large health care systems.

Therapists' experiences with a new treatment combining physical exercise and dietary therapy (the PED-t) for eating disorders: an interview study in a randomised controlled trial at the Norwegian School of Sport Sciences

OBJECTIVES

The aim of the current study is to explore how therapists running a guided physical exercise and dietary therapy programme (PED-t) experience their contribution to the treatment of patients with bulimia nervosa and binge eating disorder.

METHODS

Ten therapists running the PED-t were semistructurally interviewed and the transcribed interviews were analysed using a systematic text condensation approach.

SETTING

The study was run within the context of a randomised controlled trial at the Norwegian School of Sport Sciences.

RESULTS

The therapists experienced their knowledge about physical exercise and nutrition as important and useful, and that they could share their knowledge with the patients in different ways and with confidence in their own role. They also believed that their knowledge could serve as tools for the patients' post-treatment recovery and management of their daily lives. Moreover, the therapists put much effort in adjusting their teaching to fit each individual participant. Finally, they reported their personal qualities as important to build trust and therapeutic alliance.

CONCLUSIONS

The terms 'clinical confidence' and 'alliance' may stand out as the overarching 'metacategories' covering the experiences revealed in this study. The clinical implication is that new groups of professionals may have an important role in the treatment of eating disorders.

TRIAL REGISTRATION NUMBER

NCTO2079935; Results.

Patients' and therapists' experiences with a new treatment programme for eating disorders that combines physical exercise and dietary therapy: the PED-t trial. A qualitative study protocol

INTRODUCTION

Women with bulimia nervosa and binge eating disorder often suffer for many years before they seek professional help. Evidence-based treatments like cognitive-behavioural therapy (CBT) might be poorly accessible, and about 50% of those who receive CBT respond to it. Such outcome may reflect the heterogeneous nature of eating disorders, and addressing this heterogeneity calls for expanding the portfolio of treatment options. In particular, it is important to explore such options' acceptability, tolerability and affordability expressed through experiences with the treatment. This protocol outlines the rationale and design of a qualitative study. It captures experiences from patients and therapists who were involved in a randomised controlled trial (RCT) exploring the efficacy of a new group-based treatment programme combining physical exercise and dietary therapy.

METHODS AND ANALYSIS

15 patients with bulimia nervosa or binge eating disorder, 10 therapists (physical trainers and dietitians) and 6-10 patients who dropped out of the RCT will be semistructurally interviewed. All interviews will be analysed using a systematic text condensation approach.

ETHICS AND DISSEMINATION

Results will be presented in peer-reviewed international journals, and at relevant international conferences. Key findings will be available to study participants as well as to patient organisations and health authorities. The overall study meets the intent and requirements of the Health Research Act and the Declaration of Helsinki. It is approved by the regional committee for medical research ethics (2013/1871).

TRIAL REGISTRATION NUMBER

NCT02079935; Pre-results.

Costs and returns on training investment for empirically supported psychological interventions

Objective Financial costs are a significant barrier to the uptake of empirically supported psychological interventions in clinical settings. Training may be among the largest of these costs; however, the potential magnitude of these costs is unclear. The aim of the present study was to develop a hypothetical model of potential training costs associated with adopting a novel therapy using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income. Methods Direct and indirect costs were estimated for reference categories being cognitive behavioural therapy for social anxiety disorder delivered by registered psychologists. These were based on averages of 39 workshops and eight treatment manuals available in Australia identified through online searches. Results This model demonstrated that upper cost ranges for training can exceed A$55000, and even didactic training (reading manuals, attending workshops) may cost up to A$9000. Indirect costs of forfeited income account for a substantial proportion of these costs. Conclusions This hypothetical model highlights why training costs should be considered in decisions about disseminating and implementing novel empirically supported psychological interventions, particularly within private workforces. In addition, the direct return on training investment for practitioners in private practice is unclear, and may vary based on caseloads and current treatment modalities. Initiatives to track competence, support training and identify novel training solutions may be required to ensure the sustainability of high-quality mental healthcare. What is known about the topic? Financial costs are one of the leading factors determining whether empirically supported mental health treatments are adopted or sustained. Training costs may be one of the largest costs of disseminating and implementing novel psychological therapies within existing workforces, including both direct (e.g. workshop fees) and indirect (e.g. lost income) costs. However, little is understood about the potential magnitude of these costs. What does this paper add? This paper presents a hypothetical modelling of potential costs associated with adopting a novel therapy, with reference categories for an empirically supported treatment (cognitive behaviour therapy) for one mental disorder (social anxiety disorder) for one mental health profession (psychologist). This model was developed and populated using systematic review of anticipated training durations and publicly available data on workshop costs, training materials and income. What are the implications for practitioners? With potential costs for adopting one novel psychological intervention exceeding A$55000, we highlight why training costs and pathways should be a focal point for ensuring the sustainable provision of high-quality mental healthcare in Australia.

Exploring the perceived usefulness of practical food groups in day treatment for individuals with eating disorders

BACKGROUND/AIM

Recovery from eating disorders is a challenging process. Emerging literature suggests that occupational therapists may provide a useful contribution in delivering purposeful eating-related interventions as a potential treatment to support sustained cognitive and behavioural changes for individuals with eating disorders. This study aimed to evaluate participants' perceptions of the contribution of occupational therapy practical food groups (food based outings and cooking groups) in supporting their functional recovery.

METHODS

Individuals attended practical food groups as part of standard treatment at an outpatient eating disorders day program. Ninety-nine participants completed questionnaires at discharge and up to three follow-up points (6, 12 and 24 months). Questions related to practical food groups were analysed, exploring participants' experiences and perceived usefulness of groups using rating-scale and open-ended questions. Open-ended responses were analysed using thematic analysis. Descriptive statistics were calculated for responses to rating-scale questions.

RESULTS

At discharge, participants rated the importance and usefulness of practical food groups as high (4.73 and 4.43 on 5-point scales, respectively), but tended to rate their enjoyment of the groups lower (3.50 on a 5-point scale). Some skill transfer was typically reported by participants at discharge (3.92 on a 5-point scale). One core theme, 'success through participation', emerged from qualitative comments. Six subthemes were also identified: helpful components of practical food groups; perceived benefit of exposure; impact of applying cognitive and behavioural skills; challenges affecting participation; facilitating adaptation; and influence of eating disorders on challenging feared foods.

CONCLUSION

This study highlights that participation in practical food groups was perceived as useful in assisting individuals to improve eating behaviours and, in some circumstances, transfer these skills into their lives outside of day program. Results suggest that occupational therapists may have an important contribution in delivering these interventions to support recovery and facilitate application of adaptive coping strategies.

Maximizing the public health impact of eating disorder services: A simulation study

OBJECTIVE

Although effective interventions for eating disorders (ED) are available, the impact of health care services on a population level is far from satisfactory. A mathematical model of how health care for ED affects the population's disease burden can stimulate discussions and provide guidance about promising strategies to reduce ED-related suffering on the population level.

METHOD

The current health care situation for ED is modeled taking into account the reach and effectiveness of prevention, treatment, and aftercare, as well as incidence rates, relapse rates, and rates for spontaneous remissions. A first-order Markov model is applied and the effect of changes in single service parameters on the populations overall disease burden are simulated.

RESULTS

Improvements of treatment utilization and the reach of prevention programs would have the largest effects on the population's disease burden. Improving the efficacy of treatment, prevention, and aftercare show only limited effects.

DISCUSSION

In order to maximize the public health impact of health care for ED new models of treatment delivery as well as public health approaches to the prevention of ED are critical.

Understanding eating disorders within internalizing psychopathology: A novel transdiagnostic, hierarchical-dimensional model

BACKGROUND

Several problems with the classification and diagnosis of eating disorders (EDs) have been identified, including proliferation of 'other specified' diagnoses, within-disorder heterogeneity, and frequent diagnostic migration over time. Beyond problems within EDs, past research suggested that EDs fit better in a spectrum of internalizing psychopathology (characterized by mood and anxiety disorders) than in a separate diagnostic class.

PURPOSE

To develop a transdiagnostic, hierarchical-dimensional model relevant to ED psychopathology that: 1) reduces diagnostic heterogeneity, 2) includes important dimensions of internalizing psychopathology that are often excluded from ED diagnostic models, and 3) predicts clinical impairment.

PROCEDURES

Goldberg's (2006) method and exploratory structural equation modeling were used to identify a hierarchical model of internalizing in community-recruited adults with EDs (N=207).

FINDINGS

The lowest level of the hierarchy was characterized by 15 factors that defined specific aspects of eating, mood, and anxiety disorders. At the two-factor level, Internalizing bifurcated into Distress (low well-being, body dissatisfaction, suicidality, dysphoria, ill temper, traumatic intrusions) and Fear-Avoidance (claustrophobia, social avoidance, panic symptoms, dietary restricting, excessive exercise, and compulsions). Results showed that the lowest level of the hierarchy predicted 67.7% of the variance in clinical impairment. In contrast, DSM eating, mood, and anxiety disorders combined predicted 10.6% of the variance in impairment secondary to an ED.

CONCLUSIONS

The current classification model represents an improvement over traditional nosologies for predicting clinically relevant outcomes for EDs.

Evidence-based clinical guidelines for eating disorders: international comparison

PURPOSE OF REVIEW

The current systematic review sought to compare available evidence-based clinical treatment guidelines for all specific eating disorders.

RECENT FINDINGS

Nine evidence-based clinical treatment guidelines for eating disorders were located through a systematic search. The international comparison demonstrated notable commonalities and differences among these current clinical guidelines.

SUMMARY

Evidence-based clinical guidelines represent an important step toward the dissemination and implementation of evidence-based treatments into clinical practice. Despite advances in clinical research on eating disorders, a growing body of literature demonstrates that individuals with eating disorders often do not receive an evidence-based treatment for their disorder. Regarding the dissemination and implementation of evidence-based treatments, current guidelines do endorse the main empirically validated treatment approaches with considerable agreement, but additional recommendations are largely inconsistent. An increased evidence base is critical in offering clinically useful and reliable guidance for the treatment of eating disorders. Because developing and updating clinical guidelines is time-consuming and complex, an international coordination of guideline development, for example, across the European Union, would be desirable.

Using the Internet to Train Therapists: Randomized Comparison of Two Scalable Methods

Background

One of the major barriers to the dissemination and implementation of psychological treatments is the scarcity of suitably trained therapists. The currently accepted method of training is not scalable. Recently, a scalable form of training, Web-centered training, has been shown to have promise.

Objective

The goal of our research was to conduct a randomized comparison of the relative effects of independent and supported Web-centered training on therapist competence and investigate the persistence of the effects.

Methods

Eligible therapists were recruited from across the United States and Canada. They were randomly assigned to 1 of 2 forms of training in enhanced cognitive behavior therapy (CBT-E), a multicomponent evidence-based psychological treatment for any form of eating disorder. Independent training was undertaken autonomously, while supported training was accompanied by support from a nonspecialist worker. Therapist competence was assessed using a validated competence measure before training, after 20 weeks of training, and 6 months after the completion of training.

Results

A total of 160 therapists expressed interest in the study, and 156 (97.5%) were randomized to the 2 forms of training (81 to supported training and 75 to independent training). Mixed effects analysis showed an increase in competence scores in both groups. There was no difference between the 2 forms of training, with mean difference for the supported versus independent group being –0.06 (95% Cl –1.29 to 1.16, P=.92). A total of 58 participants (58/114, 50.9%) scored above the competence threshold; three-quarters (43/58, 74%) had not met this threshold before training. There was no difference between the 2 groups in the odds of scoring over the competence threshold (odds ratio [OR] 1.02, 95% CI 0.52 to 1.99; P=.96). At follow-up, there was no significant difference between the 2 training groups (mean difference 0.19, 95% Cl –1.27 to 1.66, P=.80). Overall, change in competence score from end of training to follow-up was not significant (mean difference –0.70, 95% CI –1.52 to 0.11, P=.09). There was also no difference at follow-up between the training groups in the odds of scoring over the competence threshold (OR 0.95, 95% Cl 0.34 to 2.62; P=.92).

Conclusions

Web-centered training was equally effective whether undertaken independently or accompanied by support, and its effects were sustained. The independent form of Web-centered training is particularly attractive as it provides a means of training large numbers of geographically dispersed therapists at low cost, thereby overcoming several obstacles to the widespread dissemination of psychological treatments.

Evolution of cognitive-behavioral therapy for eating disorders

The evolution of cognitive-behavioral therapy (CBT) for the treatment of bulimic disorders is described in this review. The impacts of successive attempts to enhance CBT such as the addition of exposure and response prevention; the development of enhanced CBT; and broadening the treatment from bulimia nervosa to binge eating disorder are considered. In addition to developing advanced forms of CBT, shortening treatment to guided self-help was the first step in broadening access to treatment. The use of technology such as computer-based therapy and more recently the Internet, promises further broadening of access to self-help and to therapist guided treatment. Controlled studies in this area are reviewed, and the balance of risks and benefits that accompany the use of technology and lessened therapist input are considered. Looking into the future, more sophisticated forms of treatment delivered as mobile applications ("apps") may lead to more personalized and efficacious treatments for bulimic disorders, thus enhancing the delivery of treatments for eating disorders.

From Efficacy to Global Impact: Lessons Learned About What Not to Do in Translating Our Research to Reach

Although members of the Association for Behavioral and Cognitive Therapies have made significant strides toward the collective goals outlined in our mission statement, we routinely acknowledge that our ability to develop empirically supported treatments exceeds our success in improving dissemination and implementation of said interventions. Further, as noted by Kazdin and Blase (2011), even if we succeeded in having every clinician worldwide administer our best treatments with excellent competency, we still would be unsuccessful in markedly impacting the worldwide burden of mental illness because most treatments require intensive labor by expensive providers. To this end, Kazdin and Blase and others call for increased use of alternative strategies. Examples include increased attention toward prevention; use of lower-cost, simplified interventions; task shifting; train-the-trainer models; community participatory research methodology; and identification of novel funding sources. The Body Project is an empirically supported, cognitive dissonance-based prevention intervention that targets body image, a well-established risk factor for eating disorders, negative affect, unhealthy weight control behaviors, smoking behavior, and decreased physical activity. Supported by a global village of researchers, community activists, and organizational partners, the Body Project is currently being implemented in 125 countries. The aim of this paper is to share lessons our team has learned in taking a prevention intervention from early testing to widespread implementation and connect these back to broader conversations occurring in our field regarding the importance of scalability and new directions in improving global mental health.

Web-Based Therapist Training in Interpersonal Psychotherapy for Depression: Pilot Study

BACKGROUND

Training mental health professionals to deliver evidence-based therapy (EBT) is now required by most academic accreditation bodies, and evaluating the effectiveness of such training is imperative. However, shortages of time, money, and trained EBT clinician teachers make these challenges daunting. New technologies may help. The authors have developed the first empirically evaluated comprehensive Internet therapist training program for interpersonal psychotherapy (IPT).

OBJECTIVE

The aim of this study was to examine whether (1) the training protocol would increase clinicians' knowledge of IPT concepts and skills and (2) clinicians would deem the training feasible as measured by satisfaction and utility ratings.

METHODS

A total of 26 clinicians enrolled in the training, consisting of (1) a Web-based tutorial on IPT concepts and techniques; (2) live remote training via videoconference, with trainees practicing IPT techniques in a role-play using a case vignette; and (3) a Web-based portal for therapists posttraining use to help facilitate implementation of IPT and maintain adherence over time.

RESULTS

Trainees' knowledge of IPT concepts and skills improved significantly (P<.001). The standardized effect size for the change was large: d=2.53, 95% CI 2.23-2.92. Users found the technical features easy to use, the content useful for helping them treat depressed clients, and felt the applied training component enhanced their professional expertise. Mean rating of applied learning was 3.9 (scale range from 1=very little to 5=a great deal). Overall satisfaction rating was 3.5 (range from 1=very dissatisfied to 4=very satisfied).

CONCLUSIONS

Results support the efficacy and feasibility of this technology in training clinicians in EBTs and warrant further empirical evaluation.

Universal prevention efforts should address eating disorder pathology across the weight spectrum: Implications for screening and intervention on college campuses

PURPOSE

Given shared risk and maintaining factors between eating disorders and obesity, it may be important to include both eating disorder intervention and healthy weight management within a universal eating disorder care delivery program. This study evaluated differential eating disorder screening responses by initial weight status among university students, to assess eating disorder risk and pathology among individuals with overweight/obesity versus normal weight or underweight.

METHODS

1529 individuals were screened and analyzed. Screening was conducted via pilot implementation of the Internet-based Healthy Body Image program on two university campuses.

RESULTS

Fifteen percent of the sample had overweight/obesity. Over half (58%) of individuals with overweight/obesity screened as high risk for an eating disorder or warranting clinical referral, and 58% of individuals with overweight/obesity endorsed a ≥10-pound weight change over the past year. Compared to individuals with normal weight or underweight, individuals with overweight/obesity were more likely to identify as Black, endorse objective binge eating and fasting, endorse that eating disorder-related concerns impaired their relationships/social life and made them feel badly, and endorse higher weight/shape concerns.

CONCLUSIONS

Results suggest rates of eating disorder pathology and clinical impairment are highest among students with overweight/obesity, and targeted intervention across weight categories and diverse races/ethnicities is warranted within universal eating disorder intervention efforts. Integrating eating disorder intervention and healthy weight management into universal prevention programs could reduce the incidence and prevalence of eating disorders, unhealthy weight control practices, and obesity among university students.

Addressing critical gaps in the treatment of eating disorders

Remarkable progress has been made in developing psychosocial interventions for eating disorders and other mental disorders. Two priorities in providing treatment consist of addressing the research-practice gap and the treatment gap. The research-practice gap pertains to the dissemination of evidence-based treatments from controlled settings to routine clinical care. Closing the gap between what is known about effective treatment and what is actually provided to patients who receive care is crucial in improving mental health care, particularly for conditions such as eating disorders. The treatment gap pertains to extending treatments in ways that will reach the large number of people in need of clinical care who currently receive nothing. Currently, in the United States (and worldwide), the vast majority of individuals in need of mental health services for eating disorders and other mental health problems do not receive treatment. This article discusses the approaches required to better ensure: (1) that more people who are receiving treatment obtain high-quality, evidence-based care, using such strategies as train-the-trainer, web-centered training, best-buy interventions, electronic support tools, higher-level support and policy; and (2) that a higher proportion of those who are currently underserved receive treatment, using such strategies as task shifting and disruptive innovations, including treatment delivery via telemedicine, the Internet, and mobile apps.

A real world dissemination and implementation of Transdiagnostic Behavior Therapy (TBT) for veterans with affective disorders

Dissemination and implementation of evidence-based psychotherapies is challenging in real world clinical settings. Transdiagnostic Behavior Therapy (TBT) for affective disorders was developed with dissemination and implementation in clinical settings in mind. The present study investigated a voluntary local dissemination and implementation effort, involving 28 providers participating in a four-hour training on TBT. Providers completed immediate (n=22) and six-month follow-up (n=12) training assessments and were encouraged to collect data on their TBT patients (delivery fidelity was not investigated). Findings demonstrated that providers endorsed learning of and interest in using TBT after the training. At six-months, 50% of providers reported using TBT with their patients and their perceived effectiveness of TBT to be very good to excellent. Submitted patient outcome data evidenced medium to large effect sizes. Together, these findings provide preliminary support for the effectiveness of a real world dissemination and implementation of TBT.

An evaluation of Access to Psychological Services Ireland: year one outcomes

OBJECTIVES

To evaluate the clinical effectiveness and cost-effectiveness of Access to Psychological Services Ireland (APSI), a primary care adult psychology service.

METHODS

A repeated measures design was used to evaluate the clinical outcomes of service users who completed an intervention. Psychological distress, depressive symptomatology and anxiety symptomatology were measured using the Clinical Outcomes in Routine Evaluation-Outcome Measure (CORE-OM), the Patient Health Questionnaire-9 (PHQ-9) and the Generalised Anxiety Disorder-7 (GAD-7), respectively. Self-reported health and economic outcomes were measured using the EQ-5D-3L and the Eco-Psy, respectively.

RESULTS

A total of 381 adults were assessed as suitable for an APSI intervention, with 198 (52%) of these completing at least one intervention. Significant reductions in psychological distress were observed for completers of guided self-help and brief cognitive behavioural therapy, with service users also showing significant reductions in anxiety and depressive symptomatology. Reliable and clinically significant change on the CORE-OM was observed for 67.9% of treatment completers. Service users reported significant improvements in their health status but did not show changes in their health service usage in the 3-month follow-up period.

CONCLUSIONS

APSI provided an accessible service model that was clinically effective in managing a range of mild to moderate mental health difficulties. The cost-effectiveness of the service model may be enhanced by offering a wider range of high-throughput interventions and by increasing the treatment completion rate.

Acceptance and Commitment Therapy modules: Differential impact on treatment processes and outcomes

A modular, transdiagnostic approach to treatment design and implementation may increase the public health impact of evidence-based psychosocial interventions. Such an approach relies on algorithms for selecting and implementing treatment components intended to have a specific therapeutic effect, yet there is little evidence for how components function independent of their treatment packages when employed in clinical service settings. This study aimed to demonstrate the specificity of treatment effects for two components of Acceptance and Commitment Therapy (ACT), a promising candidate for modularization. A randomized, nonconcurrent, multiple-baseline across participants design was used to examine component effects on treatment processes and outcomes in 15 adults seeking mental health treatment. The ACT OPEN module targeted acceptance and cognitive defusion; the ACT ENGAGED module targeted values-based activation and persistence. According to Tau-U analyses, both modules produced significant improvements in psychiatric symptoms, quality of life, and targeted therapeutic processes. ACT ENGAGED demonstrated greater improvements in quality of life and values-based activation. ACT OPEN showed greater improvements in symptom severity, acceptance, and defusion. Both modules improved awareness and non-reactivity, which were mutually targeted, though using distinct intervention procedures. Both interventions demonstrated high treatment acceptability, completion, and patient satisfaction. Treatment effects were maintained at 3-month follow up. ACT components should be considered for inclusion in a modular approach to implementing evidence-based psychosocial interventions for adults.

Reducing eating disorder risk factors: A pilot effectiveness trial of a train-the-trainer approach to dissemination and implementation

OBJECTIVE

Impediments limit dissemination and implementation of evidence-based interventions (EBIs), including lack of sufficient training. One strategy to increase implementation of EBIs is the train-the-trainer (TTT) model. The Body Project is a peer-led body image program that reduces eating disorder (ED) risk factors. This study examined the effectiveness of a TTT model at reducing risk factors in Body Project participants. Specifically, this study examined whether a master trainer could train a novice trainer to train undergraduate peer leaders to administer the Body Project such that individuals who received the Body Project (i.e., participants) would evidence comparable outcomes to previous trials. We hypothesized that participants would evidence reductions in ED risk factors, with effect sizes similar to previous trials.

METHOD

Utilizing a TTT model, a master trainer trained a novice trainer to train undergraduate peer leaders to administer the Body Project to undergraduate women. Undergraduate women aged 18 years or older who received the Body Project intervention participated in the trial and completed measures at baseline, post-treatment, and five-month follow-up. Primary outcomes included body dissatisfaction, thin ideal internalization, negative affect, and ED pathology.

RESULTS

Participants demonstrated significant reductions in thin ideal internalization, ED pathology and body dissatisfaction at post-treatment and 5-month follow-up. At 5 months, using three different strategies for managing missing data, effect sizes were larger or comparable to earlier trials for 3 out of 4 variables.

DISCUSSION

Results support a TTT model for Body Project implementation and the importance of utilizing sensitivity analyses for longitudinal datasets with missing data.

Effectiveness of a brief school-based body image intervention 'Dove Confident Me: Single Session' when delivered by teachers and researchers: Results from a cluster randomised controlled trial

This study evaluated a 90-min single session school-based body image intervention (Dove Confident Me: Single Session), and investigated if delivery could be task-shifted to teachers. British adolescents (N = 1707; 11-13 years; 50.83% girls) participated in a cluster randomised controlled trial [lessons as usual control; intervention teacher-led (TL); intervention researcher-led (RL)]. Body image, risk factors, and psychosocial and disordered eating outcomes were assessed 1-week pre-intervention, immediate post-intervention, and 4-9.5 weeks follow-up. Multilevel mixed-models showed post-intervention improvements for intervention students relative to control in body esteem (TL; girls only), negative affect (TL), dietary restraint (TL; girls only), eating disorder symptoms (TL), and life engagement (TL; RL). Awareness of sociocultural pressures increased at post-intervention (TL). Effects were small-medium in size (ds 0.19-0.76) and were not maintained at follow-up. There were no significant differences between conditions at post or follow-up on body satisfaction, appearance comparisons, teasing, appearance conversations and self-esteem. The intervention had short-term benefits for girls' body image and dietary restraint, and for eating disorder symptoms and some psychosocial outcomes among girls and boys. A multi-session version of the intervention is likely to be necessary for sustained improvements. Teachers can deliver this intervention effectively with minimal training, indicating broader scale dissemination is feasible.

TRIAL REGISTRATION

ISRCTN16782819.

Extracting body image symptom dimensions among eating disorder patients: the Profile Analysis via Multidimensional Scaling (PAMS) approach

The present study employs Profile Analysis via Multidimensional Scaling (PAMS), a procedure for extracting dimensions, in order to identify core eating disorder symptoms in a clinical sample. A large sample of patients with eating disorders (N=5193) presenting for treatment completed the Eating Disorders Inventory-2 (EDI-2; Garner, 1991), and PAMS was then employed to estimate individual profile weights that reflect the degree to which an individual's observed symptom profile approximates the pattern of the dimensions. The findings revealed three symptom dimensions: Body Thinness, Body Perfectionism, and Body Awareness. Subsequent analysis using individual level data illustrate that the PAMS profiles properly operate as prototypical profiles that encapsulate all individuals' response patterns. The implications of these dimensional findings for the assessment and diagnosis of eating disorders are discussed.

Maximizing Effectiveness Trials in PTSD and SUD Through Secondary Analysis: Benefits and Limitations Using the National Institute on Drug Abuse Clinical Trials Network "Women and Trauma" Study as a Case Example

Recent federal legislation and a renewed focus on integrative care models underscore the need for economical, effective, and science-based behavioral health care treatment. As such, maximizing the impact and reach of treatment research is of great concern. Behavioral health issues, including the frequent co-occurrence of substance use disorders (SUD) and posttraumatic stress disorder (PTSD), are often complex, with a myriad of factors contributing to the success of interventions. Although treatment guides for comorbid SUD/PTSD exist, most patients continue to suffer symptoms following the prescribed treatment course. Further, the study of efficacious treatments has been hampered by methodological challenges (e.g., overreliance on "superiority" designs (i.e., designs structured to test whether or not one treatment statistically surpasses another in terms of effect sizes) and short term interventions). Secondary analyses of randomized controlled clinical trials offer potential benefits to enhance understanding of findings and increase the personalization of treatment. This paper offers a description of the limits of randomized controlled trials as related to SUD/PTSD populations, highlights the benefits and potential pitfalls of secondary analytic techniques, and uses a case example of one of the largest effectiveness trials of behavioral treatment for co-occurring SUD/PTSD conducted within the National Drug Abuse Treatment Clinical Trials Network (NIDA CTN) and producing 19 publications. The paper concludes with implications of this secondary analytic approach to improve addiction researchers' ability to identify best practices for community-based treatment of these disorders. Innovative methods are needed to maximize the benefits of clinical studies and better support SUD/PTSD treatment options for both specialty and non-specialty healthcare settings. Moving forward, planning for and description of secondary analyses in randomized trials should be given equal consideration and care to the primary outcome analysis.

Disseminating evidence-based psychological treatments for eating disorders

The research-practice gap is of concern in the treatment of eating disorders. Despite the existence of empirically supported treatments, few receive them. The barriers to wider dissemination and implementation of evidence-based treatment include clinician attitudes towards such treatments and the lack of sufficient numbers of suitably trained therapists to provide treatment. In this review we discuss these barriers in the context of the wider issue of the dissemination and implementation of psychological treatments and review the research with regard to the treatment of eating disorders. Particular emphasis is placed on examining recent efforts to expand the availability and reach of treatments by making treatment delivery and training more scalable. We highlight promising developments and areas where further research is needed.

Evaluation of an online training program in eating disorders for health professionals in Australia

BACKGROUND

Early detection and treatment of eating disorders is instrumental in positive health outcomes for this serious public health concern. As such, workforce development in screening, diagnosis and early treatment of eating disorders is needed. Research has demonstrated both high rates of failure to accurately diagnose and treat cases early and low levels of perceived access to training in eating disorders by health professionals-representing an urgent need for clinician training in this area. However, significant barriers to the access of evidence-based training programs exist, including availability, cost and time, particularly when large geographic distances are involved. Online learning presents a solution to workforce challenges, as it can be delivered anywhere, at a fraction of the cost of traditional training, timing is user controlled, and a growing body of research is demonstrating it as effective as face-to-face training. The Centre for Eating and Dieting Disorders in Australia has developed an Online Training Program In Eating Disorders, to educate health professionals in the nature, identification, assessment and management of eating disorders. The aim of the current study was to evaluate the ability of this online learning course to improve clinician levels of knowledge, skill and confidence to treat eating disorders. As well as its effect on stigmatised beliefs about eating disorders known to effect treatment delivery.

METHODS

One-hundred-eighty-seven health professionals participated in the program. A pre training questionnaire and a post training evaluation examined participants' levels of knowledge, skill and confidence to treat eating disorders, as well attitudes and beliefs about people with eating disorders.

RESULTS

Significant improvements in knowledge, skill, and confidence to treat eating disorders was found between pre and post program assessment in health professionals who completed the course, along with a significant decrease in stigmatised beliefs about eating disorders.

DISCUSSION

The results of this study demonstrated that the online training program was an effective tool in increasing health professionals' level of knowledge, skill and confidence to treat people with eating disorders. The results also demonstrated that online training reduced health professionals' personal bias towards people with eating disorders. Limitations of this study include the use of self-report measures rather than observation of the health professional in clinical practice. As a result, it is not possible to make determinations regarding the translation of these results to clinical settings.

CONCLUSIONS

The findings of this study suggest that online training programs may present an innovative solution to the considerable workforce development challenges faced by clinicians needing training in eating disorders.

Reducing eating disorder risk factors: a controlled investigation of a blended task-shifting/train-the-trainer approach to dissemination and implementation

Recent advances in psychological intervention research have led to an increase in evidence-based interventions (EBIs), yet there remains a lag in dissemination and implementation of EBIs. Task-shifting and the train-the-trainer (TTT) model offer two potential strategies for enhancing reach of EBIs. The Body Project, an EBI found to prevent onset of eating disorders, served as the vehicle for this dissemination/implementation study. The primary aim of this study was to determine if training of peer-leaders for the Body Project could be task-shifted to undergraduate students using a hybrid task-shifting/TTT model. Our secondary aim was to determine if subgroups of participants evidenced different trajectories of change through 14-month follow-up. Regarding the first aim, we found almost no evidence to suggest that a presence of a doctoral-level trainer yielded superior participant outcomes compared to training by undergraduates alone. Regarding Aim 2, almost all classes for all variables evidenced improvement or a benign response. Additionally, for three key risk factors (thin-ideal internalization, body dissatisfaction, and ED symptoms) virtually all trajectories showed improvement. This study provides initial support for the use of a blended task-shifting/TTT approach to dissemination and implementation within prevention generally, and further support for broad dissemination of the Body Project specifically.

Clinicians' concerns about delivering cognitive-behavioural therapy for eating disorders

Despite research supporting the effectiveness of evidence-based interventions in the treatment of eating disorders, those interventions are under-utilised in routine clinical practice, possibly due to clinicians' concerns about delivering the relevant techniques. This study examined what elements of therapy clinicians worry about when delivering cognitive-behavioural therapy (CBT) for the eating disorders, and what clinician variables are associated with such concerns. The participants were 113 clinicians who used individual CBT with eating disorder patients. They completed a novel measure of concerns about delivering elements of CBT, as well as demographic characteristics and a standardised measure of intolerance of uncertainty. Clinicians worried most about body image work and ending treatment, but least about delivering psychoeducation. Their concerns fell into four distinct factors. Older, more experienced clinicians worried less about delivering the CBT techniques, but those with greater levels of prospective and inhibitory anxiety worried more about specific factors in the CBT techniques. Clinicians' capacity to tolerate uncertainty might impair their delivery of evidence-based CBT, and merits consideration as a target in training and supervision of CBT clinicians.

Reenvisioning Clinical Science: Unifying the Discipline to Improve the Public Health

We present a vision of clinical science, based on a conceptual framework of intervention development endorsed by the Delaware Project. This framework is grounded in an updated stage model that incorporates basic science questions of mechanisms into every stage of clinical science research. The vision presented is intended to unify various aspects of clinical science toward the common goal of developing maximally potent and implementable interventions, while unveiling new avenues of science in which basic and applied goals are of equally high importance. Training in this integrated, translational model may help students learn how to conduct research in every domain of clinical science and at each stage of intervention development. This vision aims to propel the field to fulfill the public health goal of producing implementable and effective treatment and prevention interventions.