Dissemination and Implementation of Cognitive Behavioral Therapy for Depression in the Kaiser Permanente Health Care System: Evaluation of Initial Training and Clinical Outcomes

Evaluation and lessons learned from the dissemination and implementation science scholars program in the national cancer prevention and control research network

Background

The Centers for Disease Control and Prevention (CDC)-funded Cancer Prevention and Control Research Network (CPCRN) has been a leader in cancer-related dissemination & implementation (D&I) science. Given increased demand for D&I research, the CPCRN Scholars Program launched in 2021 to expand the number of practitioners, researchers, and trainees proficient in cancer D&I science methods.

Methods

The evaluation was informed by a logic model and data collected through electronic surveys. Through an application process (baseline survey), we assessed scholars' competencies in D&I science domains/subdomains, collected demographic data, and asked scholars to share proposed project ideas. We distributed an exit survey one month after program completion to assess scholars' experience and engagement with the program and changes in D&I competencies. A follow-up survey was administered to alumni nine months post-program to measure their continued network engagement, accomplishments, and skills.

Results

Three cohorts completed the program, consisting of 20, 17, and 25 scholars in Years 1-3, respectively. There was a significant increase in the total D&I competency scores for all three cohorts for 4 overarching domains and 43 subdomains (MPre = 1.38 MPost = 1.89). Differences were greatest for the domain of Practice-Based Considerations (0.50 mean difference) and Theory & Analysis (0.47 mean difference). Alumni surveys revealed that scholars appreciated access to D&I-focused webinars, toolkits, and training resources. 80% remain engaged with CPCRN workgroups and investigators.

Conclusions

Program evaluation with scholars and alumni helped with ongoing quality assurance, introspection, and iterative program adaptation to meet scholars' needs. This approach is recommended for large-scale capacity-building training programs.

Clinical Effects of Asynchronous Provider-Guided Practice Sessions During Blended Care Therapy for Anxiety and Depression: Pragmatic Retrospective Cohort Study

BACKGROUND

Blended care therapy models are intended to increase the efficiency and effectiveness of evidence-based psychotherapy by combining synchronous and asynchronous components of care.

OBJECTIVE

This retrospective cohort study evaluated the clinical effects of synchronous video therapy sessions and asynchronous guided practice session elements on anxiety and depression in a blended care therapy program, with a novel focus on asynchronous provider feedback messages.

METHODS

Participants were adults (N=33,492) with clinical symptoms of anxiety (Generalized Anxiety Disorder 7-item scale [GAD-7] score of ≥8) and depression (Patient Health Questionnaire 9-item scale [PHQ-9] score of ≥10) at intake. Symptom trajectories were evaluated via individual growth curve models. Time-varying covariates evaluated effects of synchronous video session attendance and the presence or absence of each asynchronous guided practice session element occurring within 7 days and 8-14 days prior to each clinical outcome assessment. Guided practice session elements included client digital lesson completion, client digital exercise completion, and feedback messages sent by providers.

RESULTS

Approximately 86.6% (29,012/33,492) of clients met criteria for clinical improvement by end of care (median 6, IQR 4-8 synchronous sessions). Synchronous video session attendance and client digital lesson completion in the past 7 days and in the past 8-14 days were each uniquely and significantly associated with lower GAD-7 scores (video session effects: bsession7=-0.82, bsession8-14=-0.58, P values<.001; digital lesson effects: blesson7=-0.18, blesson8-14=-0.26, P values <.001) and PHQ-9 scores (video session effects: bsession7=-0.89, bsession8-14=-0.67, P values <.001; digital lesson effects: blesson7=-0.12, blesson8-14=-0.30, P values <.001). Client digital exercise completion in the past 8-14 days was significantly associated with lower GAD-7 scores (bexercise8-14=-0.10; P<.001) but exercise completion in the 7 days prior to clinical outcome assessment was not (bexercise7=0.00; P=.89). Exercise completion in the past 7 days was significantly associated with lower PHQ-9 scores (bexercise7=-0.16; P<.001) but exercise completion in the past 8-14 days was not (bexercise8-14=-0.05; P=.09). Provider feedback messaging in the past 7 days and in the past 8-14 days was significantly associated with lower GAD-7 and PHQ-9 scores, respectively (GAD-7: bfeedback7=-0.12, P<.001; bfeedback8-14=-0.07, P=.004; PHQ-9: bfeedback7=-0.15, P<.001; bfeedback8-14=-0.08, P=.01).

CONCLUSIONS

Provider feedback between synchronous therapy sessions provided significant benefit for symptom reduction, beyond the effects of client digital engagement and synchronous video sessions. When guided practice sessions are well integrated into care, blended care therapy provides meaningful improvements upon the traditional, synchronous session-only therapy model. Provider guidance and feedback for clients between synchronous sessions support more efficient and effective mental health care overall.

Impact of real-world implementation of evidence-based insomnia treatment within a large payor-provider health system: initial provider and patient-level outcomes

Study Objectives

Insomnia has substantial and wide-ranging negative effects on clinical and functional outcomes and on health care expenditures, yet few individuals receive gold-standard insomnia treatment. The current article examines provider and patient outcomes associated with real-world implementation of Cognitive Behavioral Therapy for Insomnia (CBT-I), as part of a pilot initiative designed to establish initial capability for evidence-based insomnia treatment within one of the largest payor-provider systems in the United States.

Methods

Provider training outcomes were assessed using the CBT-I Competency Rating Scale and self-report measures. Patient outcomes were assessed using the Insomnia Severity Index (ISI) and Patient Health Questionnaire-9.

Results

All clinicians (N = 11) achieved competency in CBT-I and reported large increases in knowledge and confidence related to insomnia and insomnia treatment. Clinicians also reported high intention to deliver CBT-I and significant improvements in overall job satisfaction following competency-based CBT-I training. Among all patients who initiated CBT-I (N = 48), mixed effects modeling demonstrated significant reduction in average ISI scores (12.57 to 5.88, SEs = 1.08-1.14). More than two-thirds of patients (68.8%) completed treatment. Among completers of this brief treatment, mean insomnia severity improvement was 71% (Hedges g = 1.56).

Conclusions

Findings provide support for the feasibility and effectiveness of real-world CBT-I implementation, extending past findings to a private, payor-provider context. Patient and provider-level outcomes suggest the significant opportunity private systems may have in increasing the availability of gold-standard treatment for insomnia.

Effects of Training in Cognitive Behavioural Therapy and Motivational Interviewing on Mental Health Practitioner Behaviour: A Systematic Review and Meta-Analysis

Effective training of mental health professionals is crucial for bridging the gap between research and practice when delivering cognitive behavioural therapy (CBT) and motivational interviewing (MI) within community settings. However, previous research has provided inconclusive evidence regarding the impact of training efforts. The current study aimed to systematically search, review and synthesize the literature on CBT and MI training to assess its effect on practitioner behavioural outcomes. Following prospective registration, a literature search was conducted for studies where mental health practitioners were exposed to training in face-to-face CBT or MI, reporting on at least one quantitative practitioner behavioural outcome. A total of 116 studies were eligible for the systematic review, and 20 studies were included in four meta-analyses. The systematic review highlights the need to establish psychometrically valid outcome measures for practitioner behaviour. Results of the meta-analyses suggest that training has a greater effect on practitioner behaviour change compared to receiving no training or reading a treatment manual. Training combined with consultation/supervision was found to be more effective than training alone, and no differences were found between face-to-face and online training. Results should be interpreted with caution due to methodological limitations in the primary studies, large heterogeneity, and small samples in the meta-analyses. Future directions are discussed.

Systematic review of training in cognitive-behavioral therapy: Summarizing effects, costs and techniques

With the steadily growing importance of psychotherapeutic care, there is also an increasing need for high-quality training. We analyze the literature published between 2009 and 2022 on the effectiveness of training in cognitive behavioral therapy. The review addresses current gaps in the literature by focusing on the description of specific training components and their associated costs, as well as examining therapist-level predictors of training effectiveness. Our findings confirm the effect of additional supervision on both therapist competence and patient outcomes. Instructor-led training and self-guided web-based training seem to moderately increase competence, especially when targeting specific and highly structured treatments or skills. The level of prior training and experience of a therapist appears to predict the strength of training-related gains in competence. Few studies analyzed the differential effect of certain elements of training (e.g., the amount of active learning strategies) and training costs were generally not reported. Future studies should replicate or expand the existing evidence on active ingredients and therapist-level predictors of training effectiveness. Costs should be systematically reported to enhance the comparability of different training strategies.

Building Capacity in Implementation Science for Cancer Prevention and Control Through a Research Network Scholars Program

Building capacity of researchers and practitioners in the dissemination and implementation (D&I) of evidence-based interventions is greatly needed to improve cancer prevention and control. A diverse workforce trained in D&I science is critical for improving cancer outcomes and reducing cancer-related health disparities. The US Centers for Disease Control and Prevention's (CDC) Cancer Prevention and Control Research Network (CPCRN) Scholars Program aimed at training students, researchers, and practitioners in D&I for cancer prevention and control launched in 2021. The purpose of this paper is to describe the creation of the training program, curriculum, and evaluation plans, and to present the baseline results and lessons learned. CPCRN investigator and partner input and formative interviews (n = 16) with assistant professors, postdoctoral fellow, doctoral and undergraduate students, and a program manager guided development of the program. Twenty of 24 applicants were accepted into the inaugural year of the program. The majority of accepted scholars identified as female (80%) and were graduate students (50%). Thirty-five percent were of racially diverse backgrounds. Most self-rated their previous D&I experience and competencies at a beginner level. The multi-step approach used for development of this training program and lessons learned will be helpful for others collaborating on preparing the research and practice workforce in D&I science.

Does the working alliance mediate the therapist competence-outcome relationship in cognitive behavior therapy for depression?

Objective: This study examined whether the working alliance mediated the effect of therapist competence on subsequent depression symptomology during Cognitive Behavioral Therapy (CBT). We also tested the potential moderation effect of alliance on subsequent depressive symptomology, based on participants' cognitive aptitude.Method: A total of 86 sessions were coded as the prediction interval across 50 patient-therapist dyads (age M = 39.22, SD = 8.78; 76% female). While accounting for prior depression, competence, and alliance levels, predictors were assessed early treatment (session 1; n = 45 sessions), mid-treatment (session 12; n = 41 sessions), and depressive symptomology was assessed at the subsequent session to the predictor assessments to investigate within-session variability of process variables.Results: Mediation analysis revealed that the effect of early treatment therapist competence on symptom change was mediated by alliance (indirect effect: β = -.17, 95% percentile bootstrap CI [-.32, -.01]). The positive association involving early treatment alliance and next session outcome was conditional upon low cognitive aptitude levels.Conclusions: Our result offers preliminary support for alliance as a mediator of the effect of competence, and that alliance-outcome relations vary as a function of client aptitude. These novel findings require replication and extension.

Learning gains from a one-day training in acceptance-based behavior therapy

The primary method of training for individual licensed mental health professionals is continuing education (CE). Despite the promise of CE as a vehicle for training clinicians in evidence-based practices, only a handful of studies have examined the efficacy of trainings delivered in the CE context. Moreover, these studies have focused on a few very specific therapeutic approaches. There is a growing body of evidence supporting Acceptance-based Behavior Therapy (ABBT) as a treatment for generalized anxiety disorder (GAD) and related disorders. Training workshops aimed at disseminating ABBT are regularly conducted across and outside the United States, yet the effectiveness of these trainings is unknown. The goal of this study was to examine learning outcomes among licensed mental health professionals following a six-hour CE training in ABBT. Data were collected at baseline, post-training, and at three-month follow-up. Participants demonstrated a statistically significant increase in learning on an ABBT Knowledge Questionnaire and in their coded responses to client scenarios from baseline to follow-up, although there was a significant decline in knowledge between post and follow-up. Beyond baseline ABBT knowledge, attitude towards evidence-based practice was the only predictor of change in knowledge over time.