A comparison of telehealth versus in-person group therapy: Results from a DBT-based dual diagnosis IOP

Measurement-Based Care in a Remote Intensive Outpatient Program: Pilot Implementation Initiative

BACKGROUND

The ongoing mental health crisis, especially among youth, has led to a greater demand for intensive treatment at the intermediate level, such as intensive outpatient programs (IOPs). Defining best practices in remote IOPs more broadly is critical to understanding the impact of these offerings for individuals with high-acuity mental health service needs in the outpatient setting. Measurement-based care (MBC), or the routine and systematic collection of patient-reported data throughout the course of care to make meaningful changes to treatment, is one such practice that has been shown to improve patient outcomes in mental health treatment. Despite the literature linking MBC to beneficial clinical outcomes, the adoption of MBC in clinical practice has been slow and inconsistent, and more research is needed around MBC in youth-serving settings.

OBJECTIVE

The aim of this paper is to help bridge these gaps, illustrating the implementation of MBC within an organization that provides remote-first, youth-oriented IOP for individuals with high-acuity psychiatric needs.

METHODS

A series of 2 quality improvement pilot studies were conducted with select clinicians and their clients at Charlie Health, a remote IOP program that treats high-acuity teenagers and young adults who present with a range of mental health disorders. Both studies were carefully designed, including thorough preparation and planning, clinician training, feedback collection, and data analysis. Using process evaluation data, MBC deployment was repeatedly refined to enhance the clinical workflow and clinician experience.

RESULTS

The survey completion rate was 80.08% (3216/4016) and 86.01% (4218/4904) for study 1 and study 2, respectively. Quantitative clinician feedback showed marked improvement from study 1 to study 2. Rates of successful treatment completion were 22% and 29% higher for MBC pilot clients in study 1 and study 2, respectively. Depression, anxiety, and psychological well-being symptom reduction were statistically significantly greater for MBC pilot clients (P<.05).

CONCLUSIONS

Our findings support the feasibility and clinician acceptability of a rigorous MBC process in a real-world, youth-serving, remote-first, intermediate care setting. High survey completion data across both studies and improved clinician feedback over time suggest strong clinician buy-in. Client outcomes data suggest MBC is positively correlated with increased treatment completion and symptom reduction. This paper provides practical guidance for MBC implementation in IOPs and can extend to other mental health care settings.

Assessing the implementation of suicide-focused treatments delivered in hybrid telemental health format in a real-world setting

OBJECTIVE

The purpose of this study was to assess the implementation of suicide-focused treatments delivered via a hybrid telemental health (TMH) and in-person format.

METHOD

This study was conducted at four university counseling centers (UCCs) across the United States. Treatment-seeking clients were recruited from their local UCCs and participated in adaptive treatment strategies (ATSs) involving Treatment as Usual (TAU), Collaborative Assessment and Management of Suicidality (CAMS), and Dialectical Behavior Therapy (DBT). Implementation outcomes, including appropriateness, acceptability, feasibility, fidelity, safety, and client satisfaction, were assessed. UCC clinicians participated in qualitative interviews focused on implementation of TMH for clients presenting with suicidal ideation (SI).

RESULTS

Overall, treatments delivered via hybrid format were reported to be appropriate, acceptable, feasible, and satisfactory by clinicians and clients. Implementation of TMH was reported to be equivalent to in-person treatment across multiple measurement methods.

CONCLUSION

Results from this study demonstrate that TMH is an implementable treatment modality for addressing suicidality, particularly for college students presenting to UCCs with SI. This study has implications for real-world clinical settings planning to offer hybrid treatment modalities to address SI.Trial registration: ClinicalTrials.gov identifier: NCT04728815.

A new insomnia treatment service: the benefits and challenges of establishing a trainee-led service

Chronic insomnia is undertreated in the UK despite being a common mental disorder that severely affects quality of life. The lead author, a psychiatry trainee, implemented a new group cognitive-behavioural therapy for insomnia (CBT-I) service for secondary care patients in London with chronic insomnia and comorbid mental illness. Expertise was propagated by trainees teaching other trainees. Nine patients completed all sessions, all with moderate-to-severe insomnia on the Insomnia Severity Index (ISI) at baseline assessment (mean score 21.6). All patients seen at follow-up had improved, scoring in the 'subthreshold' or 'no clinically significant insomnia' ranges on the ISI (mean 6.6), and all with improvements in comorbid psychiatric symptoms and functioning. This evaluation demonstrates that group CBT-I can be easily learned and delivered by those without formal CBT or sleep medicine training. This could increase the availability and accessibility of treatment. However, bureaucratic challenges were faced, and trainee-led innovations should be better facilitated.

Changes in mental health services in response to the COVID-19 pandemic in high-income countries: a rapid review

BACKGROUND

Severe deterioration in mental health and disrupted care provision during the COVID-19 increased unmet needs for mental health. This review aimed to identify changes in mental health services for patients in response to the pandemic and understand the impact of the changes on patients and providers.

METHODS

Following the Cochrane guidance for rapid reviews, Cochrane CENTRAL, MEDLINE, Embase and PsycInfo were searched for empirical studies that investigated models of care, services, initiatives or programmes developed/evolved for patients receiving mental health care during COVID-19, published in English and undertaken in high-income countries. Thematic analysis was conducted to describe the changes and an effect direction plot was used to show impact on outcomes.

RESULTS

33 of 6969 records identified were included reporting on patients' experiences (n = 24), care providers' experiences (n = 7) and mixed of both (n = 2). Changes reported included technology-based care delivery, accessibility, flexibility, remote diagnostics and evaluation, privacy, safety and operating hours of service provision. These changes had impacts on: (1) care access; (2) satisfaction with telehealth; (3) comparability of telehealth with face-to-face care; (4) treatment effectiveness; (5) continuity of care; (6) relationships between patients and care providers; (7) remote detection and diagnostics in patients; (8) privacy; (9) treatment length and (10) work-life balance.

CONCLUSIONS

A shift to telecommunication technologies had a significant impact on patients and care providers' experiences of mental health care. Improvements to care access, flexibility, remote forms of care delivery and lengths of operating service hours emerged as crucial changes, which supported accessibility to mental health services, increased attendance and reduced dropouts from care. The relationships between patients and care providers were influenced by service changes and were vastly depending on technological literacy and context of patients and availability and care access ranging from regular contact to a loss of in-person contact. The review also identified an increase in care inequality and a feeling of being disconnected among marginalised groups including homeless people, veterans and ethic minority groups. Telehealth in mental care could be a viable alternative to face-to-face service delivery with effective treatment outcomes. Further research is needed to better understand the impact of the changes identified particularly on underserved populations.

Can dialectical behavior therapy skills group treat social anxiety disorder? A brief integrative review

The purposes of this brief integrative review are to identify and critically evaluate recent work in the area of Dialectical Behavior Therapy-Skills Group (DBT-SG) for Social Anxiety Disorder (SAD) with suicidal ideation (SI) and to suggest further how DBT-based skills may be applied to cognitive maintenance factors of SAD. Accordingly, we first evaluate the relevance of DBT in treating SI in other disorders. Second, we evaluate the relationship between SI and SAD, providing considerations for the complexity of comorbid disorders and presentations. Finally, we extend this knowledge to discuss considerations for the use of DBT-SG skills to target specific etiological and maintenance elements of SAD, with a focus on four themes (interpersonal effectiveness, mindfulness, emotion regulation, and distress tolerance). Overall, we conclude that DBT-SG may prove beneficial in reducing SI and symptoms in SAD that impact social and emotional functioning.

Applications of dialectical behavioural therapy in the perinatal period: A scoping review

Psychological distress is the most common complication of pregnancy. High-risk concerns can include severe emotion dysregulation, suicidality and self-injury, and health risk behaviours, which bear substantial consequences for caregivers and families. Yet, effective, comprehensive interventions for high-risk caregivers have received limited attention. Dialectical behaviour therapy (DBT) is a frontline treatment for such concerns. Accordingly, we conducted a scoping review on the implementation of DBT in the perinatal period. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were followed. Seven studies were identified; study designs included case studies and single-arm pilot trials. Most studies used DBT-informed protocols with significant adaptations, few included multiple components of DBT (i.e. skills group, individual therapy, phone coaching and consultation team), and none met criteria for adherent delivery of all four modes of DBT treatment. Findings suggest DBT-informed interventions may be successfully implemented to treat a range of perinatal mental health symptoms, including borderline personality disorder, depression, anxiety, and post-traumatic stress, and to promote emotion regulation and positive parenting behaviours. While results provide preliminary support for perinatal DBT, this literature is scant and empirical rigour considerably lacking. Clinical implications and future directions are outlined to aid researchers and providers in addressing the ongoing perinatal mental health crisis and developing sorely needed interventions to address the needs of high-risk caregivers.

Psychosocial interventions for the prevention of self-harm repetition: protocol for a systematic review and network meta-analysis

INTRODUCTION

Suicide is an important public health problem. Providing evidence-based psychosocial interventions to individuals presenting with self-harm is recognised as an important suicide prevention strategy. Therefore, it is crucial to understand which intervention is most effective in preventing self-harm repetition. We will evaluate the comparative efficacy of psychosocial interventions for the prevention of self-harm in adults.

METHODS AND ANALYSIS

We will perform a systematic review and network meta-analysis (NMA) of randomised controlled trials (RCTs) testing psychosocial interventions for the prevention of self-harm repetition. We will include RCTs in adults (mean age: 18 years or more) who presented with self-harm in the 6 months preceding enrolment in the trial. Interventions will be categorised according to their similarities and underpinning theoretical approaches (eg, cognitive behavioural therapy, case management). A health sciences librarian will update and adapt the search strategy from the most recent Cochrane pairwise systematic review on this topic. The searches will be performed in MEDLINE (Ovid), Embase (Ovid), PsycInfo (Ovid), CINAHL (EBSCO), Cochrane Central (Wiley), Cochrane Protocols (Wiley), LILACS and PSYNDEX from 1 July 2020 (Cochrane review last search date) to 1 September 2023. The primary efficacy outcome will be self-harm repetition. Secondary outcomes will include suicide mortality, suicidal ideation and depressive symptoms. Retention in treatment (ie, drop-outs rates) will be analysed as the main acceptability outcome. Two reviewers will independently assess the study eligibility and risk of bias (using RoB-2). An NMA will be performed to synthesise all direct and indirect comparisons. Ranked forest plots and Vitruvian plots will be used to represent graphically the results of the NMA. Credibility of network estimates will be evaluated using Confidence in NMA (CINeMA).

ETHICS AND DISSEMINATION

As this is the protocol for an aggregate-data level NMA, ethical approval will not be required. Results will be disseminated at national/international conferences and in peer-review journals.

TRIAL REGISTRATION NUMBER

CRD42021273057.