Implementing evidence-based practices in routine mental health service settings

Family Involvement in Routine Services for Individuals With Severe Mental Illness: Scoping Review of Barriers and Strategies

OBJECTIVE

The authors investigated barriers to practices that promote family involvement in mental health services, focusing on individuals with severe mental illness, their families, and mental health providers. Additionally, the authors sought to identify strategies to facilitate family involvement in mental health provision to highlight the engagement process in routine practice and propose future directions for organizations to establish a family-friendly environment.

METHODS

Systematic searches for literature published from January 1990 to March 2023 were conducted in PsycInfo, PubMed, CINAHL, Sociological Abstracts, and Scopus databases. Gray literature searches and backward and forward snowballing strategies were also used.

RESULTS

Forty-six articles were reviewed, revealing contextual backgrounds and engagement practices that hindered family involvement. Inconsistencies in family involvement stemmed from organizational culture, societal attitudes, and providers' negating of family expertise. Uncertainty regarding confidentiality policies and the absence of practice guidelines posed challenges for providers. Negative experiences of families within the mental health system along with variable commitment also hampered involvement. Some service users declined family involvement because of privacy concerns and differing expectations regarding the extent of involvement. Promoting a shared culture of family work, integrating practice standards, and engaging in professional development activities emerged as key strategies.

CONCLUSIONS

A gap exists between implementing policies and practices for family involvement in mental health treatment. Without cultural and organizational shifts in support of working with families, the uptake of family involvement practices will remain inadequate. Each stakeholder has different perceptions of the barriers to family involvement, and family involvement will remain elusive without a shared agreement on its importance.

Identifying Competencies of the ACT Program Nurse Using the DACUM Method

The nurse role on an Assertive Community Treatment (ACT) team requires a specialized set of skills in psychiatric community-based care. While the ACT model has existed for fifty years, no nationally recognized standard curriculum to train ACT nurses has been developed. The ACT Nursing Project described in this paper aimed to create a competency-based on-board training program using the Developing a Curriculum (DACUM) method. Eight ACT nurses from three states served as the expert panel to create a DACUM chart detailing the full set of nine duties and 127 tasks required of ACT nurses. To verify the DACUM results, 57 ACT nurses from four states completed a survey and confirmed that 80% of the tasks identified by the expert panel were also performed by the validation sample of ACT nurses. This paper describes how the DACUM duties and tasks provided the framework to develop onboard training curriculum for ACT program nurses. The next step is to pilot the onboard training curriculum to newly hired ACT nurses to ensure they are equipped to meet the complex needs of people living with serious mental illness, and to increase their competency, job satisfaction and decrease the high annual turnover rate among ACT nurses.

Validity Evidence for an Observational Fidelity Measure to Inform Scale-Up of Evidence-Based Interventions

As evidence-based interventions are scaled, fidelity of implementation, and thus effectiveness, often wanes. Validated fidelity measures can improve researchers' ability to attribute outcomes to the intervention and help practitioners feel more confident in implementing the intervention as intended. We aim to provide a model for the validation of fidelity observation protocols to guide future research studying evidence-based interventions scaled-up under real-world conditions. We describe a process to build evidence of validity for items within the Session Review Form, an observational tool measuring fidelity to interactive drug prevention programs such as the Botvin LifeSkills Training program. Following Kane's (2006) assumptions framework requiring that validity evidence be built across four areas (scoring, generalizability, extrapolation, and decision), confirmatory factor analysis supported the hypothesized two-factor structure measuring quality of delivery (seven items assessing how well the material is implemented) and participant responsiveness (three items evaluating how well the intervention is received), and measurement invariance tests suggested the structure held across grade level and schools serving different student populations. These findings provide some evidence supporting the extrapolation assumption, though additional research is warranted since a more complete overall depiction of the validity argument is needed to evaluate fidelity measures.

Evidence-based brief interventions targeting acute mental health presentations for children and adolescents: systematic review

BACKGROUND

Brief intervention services provide rapid, mobile and flexible short-term delivery of interventions to resolve mental health crises. These interventions may provide an alternative pathway to the emergency department or in-patient psychiatric services for children and young people (CYP), presenting with an acute mental health condition.

AIMS

To synthesise evidence on the effectiveness of brief interventions in improving mental health outcomes for CYP (0-17 years) presenting with an acute mental health condition.

METHOD

A systematic literature search was conducted, and the studies' methodological quality was assessed. Five databases were searched for peer-reviewed articles between January 2000 and September 2022.

RESULTS

We synthesised 30 articles on the effectiveness of brief interventions in the form of (a) crisis intervention, (b) integrated services, (c) group therapies, (d) individualised therapy, (e) parent-child dyadic therapy, (f) general services, (g) pharmacotherapy, (h) assessment services, (i) safety and risk planning and (j) in-hospital treatment, to improve outcomes for CYP with an acute mental health condition. Among included studies, one study was rated as providing a high level of evidence based on the National Health and Medical Research Council levels of evidence hierarchy scale, which was a crisis intervention showing a reduction in length of stay and return emergency department visits. Other studies, of moderate-quality evidence, described multimodal brief interventions that suggested beneficial effects.

CONCLUSIONS

This review provides evidence to substantiate the benefits of brief interventions, in different settings, to reduce the burden of in-patient hospital and readmission rates to the emergency department.

Growing stronger together: Implementing the Strengthening Families Program with Indigenous communities

BACKGROUND

Child welfare agencies commonly seek to use evidence-based programs (EBPs) for their demonstrated results. Challenges remain in adapting programs to fit for Indigenous populations. We suggest that relationality holds promise as a guide in the implementation of EBPs with Indigenous families and children.

OBJECTIVE

We provide the story of a culturally integrated implementation of the EBP, Strengthening Families Program (SFP), with Indigenous families.

PARTICIPANTS AND SETTING

Insights from the staff who implemented SFP, project leadership and a community steering committee were brought together to create the collective implementation story.

METHODS

A relational approach was used in thematic analysis with a focus on the three Rs - responsibility, respect, and reciprocity- that support Indigenous knowledge organization.

RESULTS

Findings offer insight into cultural integrations in the implementation of SFP. The program centered Indigenous and community identities through meals, gifts, parenting practice examples and discussions tailored by each group of families and staff. Practices related to responsibility, respect and reciprocity each proved to be essential concepts in the relationship building among caregivers, children, SFP staff, project leadership, and community supporters that led to program success.

CONCLUSION

Cultural integration created a space that reflected Indigenous knowledge relationality. It respected the uniqueness among groups of families who participated in the evidence-based SFP. Our story supports the importance of having Indigenous staff and group leaders to guide cultural integration in relationship with tribal communities.

Caring as the unacknowledged matrix of evidence-based nursing

In this article, we explicate evidence-based nursing (EBN), critically appraise its framework and respond to nurses' concern that EBN sidelines the caring elements of nursing practice. We use resources from care ethics, especially Vrinda Dalmiya's work that considers care as crucial for both epistemology and ethics, to show how EBN is compatible with, and indeed can be enhanced by, the caring aspects of nursing practice. We demonstrate that caring can act as a bridge between 'external' evidence and the other pillars of the EBN framework: clinical expertise; patient preferences and values. Drawing on an influential EBN handbook, section 1 presents the aims and features of EBN, including the normative principle that EBN should take place within a 'context of caring'. We aim to understand this context and whether it can be neatly detached from the EBN framework, as the handbook seems to suggest. In section 2, we highlight the grounds for resistance to EBN from the nursing community, before mounting the argument that nursing practices can be understood fruitfully through feminist care ethics and/or virtue ethics lenses. In section 3, we deepen that analysis using Dalmiya's concepts of care-knowing and care as a hybrid ethico-epistemic virtue, which are ideally suited to the complex practices of nursing. In section 4, we bring this rich understanding of care into conversation with EBN, showing that its framework cannot be adequately theorised without paying proper attention to care. Caring can be neither an innocuous background assumption of nor an afterthought to the EBN framework.

Implementation of early intervention clinical services within the National Health System in Italy: Third wave survey with focus on structures, resources, and fidelity to the evidence-based model

BACKGROUND

Early intervention in psychosis (EIP) is a well-established approach aimed at detecting and treating early signs and symptoms of psychosis to prevent its long-term consequences. The present study aimed at detailing the current status of EIP services in Italy, covering all the Departments of Mental Health (DMHs) operating in 2018.

METHODS

All directors of public DMHs operating in Italy in 2018 (n = 127) were invited to fill in a Census form about EIP structure and activities. The first episode psychosis services fidelity scale (FEPS-FS) was used to investigate fidelity to the EIP model of the centre.

RESULTS

An active EIP service was reported by 41 DMHs (32% of the total DMHs; 56% of those who took part in the survey). Most EIP services had an autonomous team. The large majority of the Italian EIP centres provided psychosocial interventions to their patients, principally psychotherapy, family support, and psychoeducation. Among those with an active EIP, 29 DMHs filled in the FEPS-FS. Internal consistency was good when based on the replies of the respondents, but reliability was weak when measured on the basis of an independent evaluation (Cohen's kappa = 0.571). The fidelity to the guidelines for early intervention was uneven, with some criteria met by most centres, especially those peculiar to the Italian community psychiatry.

CONCLUSION

A further spreading of the early intervention model across the Italian DMHs was found. A lack of resources might limit the use of specific psychosocial treatments, such as cognitive-behavioural therapy or manualized family support.

The impact of module dosage on treatment response in a modular transdiagnostic intervention for sleep and circadian dysfunction (TranS-C)

The efficacy of modular evidence-based psychological treatments is promising, yet variation in module delivery is understudied. This study evaluated module delivery of the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) and its impact on patient outcomes. Adults (N = 108) with serious mental illness and sleep and circadian dysfunction treated in a community setting were randomized to receive TranS-C plus usual care, or 6 months of usual care followed by delayed treatment with TranS-C. Data from both conditions were combined to maximize power. These secondary analyses tested whether the "dosage" of module delivery (defined as the proportion of total sessions in which a module was delivered) predicted treatment response, measured as functional impairment, psychiatric symptoms, sleep and circadian dysfunction, and sleep health, at post-treatment and 6-month follow-up. Higher dosages of seven modules were associated with improvement in the outcome variables (βs = -0.11-0.44; ps = 0.000-0.030). Higher dosages of three modules were associated with a worsening of one or two outcome variables (βs = 0.22-0.29; ps = 0.001-0.043). Higher dosages of the remaining modules were not associated with outcomes. Although more evidence is needed, it may be wise to consider focusing provider trainings on ensuring fidelity to certain modules, given limited training time in community settings. ClinicalTrials.gov Identifier: NCT02469233, registered June 9, 2015.

Effectiveness of Illness Management and Recovery program on people with severe mental illnesses: a systematic review and meta-analysis

Background

The Illness Management and Recovery (IMR) program has been established in response to the challenges faced by people with severe mental illnesses (SMIs). The program emphasizes the self-management of mental health conditions and the achievement of personally meaningful goals. However, reviews on its efficacy remain scarce, especially in recent years.

Objective

This review aimed to examine the efficacy of IMR in improving personal-recovery outcomes among people with SMIs.

Methods

A search was conducted on seven databases (CINAHL, Embase, ProQuest, PsycINFO, PubMed, Scopus, and Web of Science) from inception to February 2022, without limits on the dates and types of publications. Studies were included if they had examined the efficacy of IMR in one or more outcomes, investigated at least one group of participants, and been published in English. The participants were adults (at least 16 years of age) with a formal diagnosis of at least one SMI.

Results

Fourteen studies were included in this review, and eight outcomes were examined: personal recovery, global functioning, social functioning, hope, perceived social support, quality of life, substance abuse, and knowledge of mental illness. There is limited evidence on the superiority of IMR to existing treatment plans or other interventions in improving the outcomes of interest among people with SMIs. However, the low attendance rates in many included studies suggest the presence of a threshold of exposure to IMR beyond which its treatment effects could be observed. Suggestions for future IMR implementation are discussed.

Conclusions

The IMR program may serve as an alternative or complementary intervention for people with SMIs, especially with enhanced program exposure and access to resource materials.

Systematic review registration

https://inplasy.com/inplasy-2022-10-0005/.

Examination of Adaptations to the Evidence Based Supported Employment Model: Individual Placement and Support

Individual Placement and Support (IPS) is a long-standing and innovative employment service for individuals with mental illness with dozens of clinical trials demonstrating effectiveness. Little is known, however, about intentional adaptations to IPS, especially those outside of the context of research studies. Using an implementation science framework, we conducted an exploratory study to better understand the characteristics of stakeholder-reported adaptions to IPS, the impetus for their development, and perceived impacts. We conducted qualitative interviews to analyze and describe these adaptations. Numerous adaptations of IPS were found that address the needs of new and underserved populations both within and outside of the mental health field. Programs reported adapting IPS because of the dearth of other evidence-based employment services, to serve diverse populations in need, and based on financial incentives. Benefits of adaptations were weighed against impacts on fidelity. As evidence-based practices (EBPs) are adapted, developers of EBPs should determine how fidelity of a program or service can be assessed or preserved in light of adaptations. This is critical with the increase in different service delivery methods, new populations, new service recipient needs, and new settings in need of EBPs.

Psychiatric rehabilitation patterns in Italy: Results from the Italian Society of Psychosocial Rehabilitation (SIRP) survey

INTRODUCTION

Psychiatric rehabilitation can be considered a bidirectional technique, designed to allow patients to achieve their personal target, focusing on the individuals' strengths and challenges related to these targets and also on the community organizations in which they will live them out. Unfortunately, psychiatric rehabilitation is too often not considered a first line treatment. Moreover, rehabilitation has been confused with a generic and rough practice, consisting of extemporary actions and aimless entertainments designed to fill "the time passing".

METHODS

The aim of this study was to increase the knowledge and awareness about the state of the art of different systems of management and funding of psychosocial rehabilitation in the Italian "real-world" rehabilitative settings, using a specifically developed questionnaire.

RESULTS

The data obtained are positive for some aspects of the rehabilitation interventions, in particular for the use of validated tools for the evaluation and revision of projects and for the trend to work on a team, even though the scarcity of evidence-based rehabilitation interventions applied in Italian psychiatric services is less encouraging.

CONCLUSION

This survey presents, at least partially, the "real-world" of rehabilitation in Italy so that we can lay the foundations for the definition of an updated, validated and shared network of what is implemented in the context of psychiatric rehabilitation.

Implementation strategies to promote measurement-based care in schools: evidence from mental health experts across the USA

BACKGROUND

Despite an established taxonomy of implementation strategies, minimal guidance exists for how to select and tailor strategies to specific practices and contexts. We employed a replicable method to obtain stakeholder perceptions of the most feasible and important implementation strategies to increase mental health providers' use of measurement-based care (MBC) in schools. MBC is the routine use of patient-reported progress measures throughout treatment to inform patient-centered, data-driven treatment adjustments.

METHODS

A national sample of 52 school mental health providers and researchers completed two rounds of modified Delphi surveys to rate the relevance, importance, and feasibility of 33 implementation strategies identified for school settings. Strategies were reduced and definitions refined using a multimethod approach. Final importance and feasibility ratings were plotted on "go-zone" graphs and compared across providers and researchers to identify top-rated strategies.

RESULTS

The initial 33 strategies were rated as "relevant" or "relevant with changes" to MBC in schools. Importance and feasibility ratings were high overall for both survey rounds; on a scale of 1 to 5, importance ratings (3.61-4.48) were higher than feasibility ratings (2.55-4.06) on average. Survey 1 responses resulted in a reduced, refined set of 21 strategies, and six were rated most important and feasible on Survey 2: (1) assess for readiness and identify barriers and facilitators; (2) identify and prepare champions; (3) develop a usable implementation plan; (4) offer a provider-informed menu of free, brief measures; (5) develop and provide access to training materials; and (6) make implementation easier by removing burdensome documentation tasks. Provider and researcher ratings were not significantly different, with a few exceptions: providers reported higher feasibility and importance of removing burdensome paperwork than researchers, providers reported higher feasibility of train-the trainer approaches than researchers, and researchers reported higher importance of monitoring fidelity than providers.

CONCLUSIONS

The education sector is the most common setting for child and adolescent mental health service delivery in the USA. Effective MBC implementation in schools has the potential to elevate the quality of care received by many children, adolescents, and their families. This empirically derived, targeted list of six implementation strategies offers potential efficiencies for future testing of MBC implementation in schools.

Testing a community developed training protocol for an evidence-based treatment

The implementation of evidence-based treatments (EBTs) in community behavioral health settings is a recommended practice, yet training experienced by community-based clinicians may require novel and creative training methods. The current study focused on creating a training protocol for Alternative for Families: a Cognitive-Behavioral Therapy from both evidence-based foundations and community-based agency feedback to promote better EBT integration into agencies. Twenty-four clinicians from three agencies were trained using a community-informed training protocol. Outcomes for clinician-reports of organizational functioning, self-reports of skill and knowledge, and observational single-subject data of clinician skills were assessed. Minimal improvements were found for clinician skills across self-report and observations. More research on tailoring trainings to meet needs of community agencies and clinicians should be explored to determine best practice in wide-scale implementation efforts.

Growth of IPS Supported Employment Programs in the United States: An Update

OBJECTIVE

Individual placement and support (IPS), an evidence-based supported employment practice, is a core service in community mental health in the United States. Several factors promote the growth of IPS, including a network of 24 states participating in a learning community devoted to expanding IPS services. This study examined growth of IPS in the United States from 2016 to 2019, comparing growth rates for states within and outside the learning community.

METHODS

This national survey included telephone interviews with 70 representatives from state mental health and vocational rehabilitation agencies in 50 states and the District of Columbia, replicating methods of a 2016 survey. The primary outcomes were the number of IPS programs and clients served. The survey inquired about four indicators of state-level support for IPS implementation and sustainment: collaboration between state agencies, independent fidelity reviews, technical assistance and training, and funding.

RESULTS

In 2019, 41 (80%) of 50 states and the District of Columbia had IPS services, with 857 IPS programs serving an estimated 43,209 clients. Between 2016 and 2019, the number of programs increased from 272 to 486 in 22 learning-community states and two learning-community counties, and from 251 to 371 in 18 states outside the learning community. State-level support for IPS was significantly greater in learning-community states, compared with non-learning-community states.

CONCLUSIONS

IPS services expanded substantially in the United States between 2016 and 2019. Learning-community states had more rapid growth and provided greater implementation support, facilitating implementation, expansion, and sustainment of high-fidelity IPS. Nevertheless, access to IPS remains limited.

Treating sleep and circadian problems to promote mental health: perspectives on comorbidity, implementation science and behavior change

Insufficient sleep and mistimed sleep are prominent, yet under-appreciated and understudied, contributors to poor mental health and to mental disorders. The evidence that improving sleep and circadian functioning is an important pathway to mental health continues to mount. The goal of this paper is to highlight three major challenges ahead. Challenge 1 points to the possibility that comorbidity is the norm not the exception for the sleep and circadian disorders that are associated with mental disorders. Hence, the sleep and circadian problems experienced by people diagnosed with a mental disorder may not fit into the neat diagnostic categories of existing nosologies nor be adequately treated with single disorder approaches. The Sleep Health Framework and the Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) are discussed as alternative approaches. Challenge 2 points to the large time lag between the development of a treatment and the availability of that treatment in routine clinical practice. This is a key reason for the emergence of implementation science, which is a flourishing, well-developed, and quickly moving field. There is an urgent need for more applications of implementation science within sleep and circadian science. Challenge 3 describes one of the greatest puzzles of our time-the need to unlock the fundamental elements of behavior change. There is potential to harness the science of behavior change to encourage widespread engagement in sleep health behavior and thereby reduce the staggering burden of sleep and circadian problems and the associated mental health problems.

Treatment for problem gambling and counselors' perception of their clinical competence: a national web survey in Sweden

BACKGROUND

Despite their crucial role in bridging science and practice, not much is known about counselors offering treatment for Problem Gambling (PG). This study maps current treatment, the type of change techniques that are prioritized in treatment and how counselors perceive their clinical competence in their work with PG clients.

METHODS

A sample of PG counselors from the healthcare and social services (N = 188, mean age: 49 years, 67% women) completed an online survey. A principal component analysis was conducted to map prioritized types of change techniques, and a multiple regression analysis was carried out to analyze predictors of counselors' role adequacy in their clinical work.

RESULTS

There was a large variation in the type of treatments offered for PG (mean 3.6). Cognitive Behavioral Therapy (CBT) and Motivational Interviewing were the most common treatments offered and motivation was rated as the most important type of change technique prioritized in the treatment of PG. A principal component analysis identified four components reflecting different types of change techniques prioritized by the counselors: (1) standard CBT, e.g., gambling cognitions, craving management, and finding alternative activities, (2) assessment of PG, (3) family orientation, i.e., involvement of concerned significant others in treatment, and (4) focus on exposure strategies. Counseling more clients monthly was associated with higher levels of willingness, adequacy and legitimacy in their clinical work with clients with PG. Additionally, offering CBT was a predictor for higher role adequacy and providing counseling on the origins of and consequences of PG.

CONCLUSION

There was a large heterogeneity among the treatments offered and what change techniques that were prioritized among the PG counselors. Clinical experience is of importance for developing competence in treating clients with PG. This finding suggests there could be benefits to establishing specialized, more visible treatment units where PG counselors could gain adequate clinical experience, thus increasing clinical competence for treating PG.

Barriers and Facilitators to Behavior Change for Individuals with Severe Mental Illness who Received the Transdiagnostic Intervention for Sleep and Circadian Dysfunction in a Community Mental Health Setting

The Transdiagnostic Intervention for Sleep and Circadian Dysfunction (TranS-C) was implemented in a community mental health center (CMHC) setting. The goal of TranS-C is to improve sleep and circadian dysfunction among people with severe mental illness. The present study uses the Theoretical Domains Framework (TDF) to uncover barriers and facilitators to changing behaviors learned in TranS-C. Adults with severe mental illness who completed TranS-C (n = 14) were given a semi-structured interview based on the TDF. Interview transcripts were independently coded using inductive and deductive coding. The most commonly coded TDF domains were Behavior Regulation, Beliefs about Consequences, Knowledge and Beliefs about Capabilities. Action planning was the most discussed facilitator and compromising sleep health in favor of time spent with loved ones was the most discussed barrier. These findings suggest that TranS-C has promising strengths and raise important barriers that can be addressed in TranS-C to improve its fit within CMHCs.

Rising co-payments and continuity of healthcare for Dutch patients with bipolar disorder: retrospective longitudinal cohort study

Background

The Netherlands has few financial barriers to access mental healthcare. However, in 2012, a sharp rise in co-payments was introduced.

Aims

We tested whether these increased co-payments coincided with less guideline-recommended continuous out-patient psychiatric care and more crisis interventions for patients with bipolar disorder.

Method

A retrospective longitudinal cohort study on a health insurance registry was performed to examine trends, and deviations from these trends, in the healthcare received by patients with bipolar disorder. Deviations of trends were tested by time-series analyses (autoregressive integrated moving average). Subsequently, the relationship between significant deviations of trends and rise in co-payments was examined. Outcome measures were the level of standard out-patient care (out-patient psychiatric care and/or medication), crisis psychiatric care and somatic care.

Results

The cohort comprised 3210 patients. During follow-up, the use of psychiatric care decreased and somatic care increased. The high rise in co-payments from 2012 onward coincided with decreases in standard out-patient care and increases in medication-only treatment, crisis psychiatric care and somatic care. Crisis intervention was highest when patients received only bipolar disorder medication. Patients receiving continuous standard out-patient care (62%) had less crisis intervention compared with the other patients.

Conclusions

Our data suggest that the rise of co-payments decreased guideline-recommended continuous out-patient psychiatric care among patients with bipolar disorder, and increased crisis psychiatric care.

Outer-context determinants in the sustainment phase of a reimbursement-driven implementation of evidence-based practices in children's mental health services

BACKGROUND

Although there is increasing investment to implement evidence-based practices (EBPs) in public systems across the USA, continued or sustained use of EBPs after initial implementation remains a challenge. The low integration of EBPs in routine practice severely limits their public health impact, highlighting the need to understand factors that affect the return on costly investments in EBP implementation. This study aims to (1) characterize trajectories of EBP delivery volume through a reimbursement-driven implementation and (2) examine impacts of system-level policy regulatory activity and state-level mental health services funding on the implementation reimbursement strategy.

METHODS

This study involved secondary data analyses. Psychotherapy administrative claims and regulatory site visit data from the Los Angeles County Department of Mental Health and California state mental health expenditures were extracted from 2010 to 2017. Multilevel regression examined EBP claims volume over time with state expenditures and regulatory compliance as predictors.

RESULTS

EBP claims volume trajectories demonstrated a rapid initial increase, followed by a period of decrease, and a small increase in the final year. State mental health expenditures increased across time reflecting increased funding availability. State mental health expenditures and system regulatory compliance were inversely related to EBP claims volume.

CONCLUSIONS

The impact of reimbursement-driven EBP implementation strategy is sensitive to multiple outer-context determinants. At the system level, commitment to fidelity of implementation regulations resulted in reduced use of the reimbursement strategy. Alternative reimbursement streams not tied to EBPs coupled with an expanded array of reimbursable services also impacted the use of the reimbursement strategy to implement EBPs.

Examining Organizational Factors Supporting the Adoption and Use of Evidence-Based Interventions

The purpose of this study was to develop a greater understanding of the factors influencing the adoption of evidence-based interventions in outpatient mental health clinics serving youth. An improved understanding of these factors can potentially improve efforts to ensure effective adoption, implementation, and sustainment of evidence-based interventions, and thus improve treatment for youth in mental health settings. This explanatory cross-sectional study involves secondary data analysis of a longitudinal randomized control intervention trial. The SEM- based model that was tested supported the primary hypothesis that a more supportive organizational climate with greater readiness for change is more likely to improve the chances for the adoption of evidence-based interventions in outpatient mental health clinics serving youths.

Relato de la experiencia en Argentina de la adaptación de un programa estandarizado guiado por la recuperación en salud mental

El concepto de recuperación, su conceptualización y consideración para las prácticas en el campo de la salud mental, pese a su significativo desarrollo a nivel mundial, están pendientes en América Latina. Como consecuencia, se registran demoras para implementar cambios estructurales en la atención especializada y las personas usuarias del sistema de salud mental se ven privadas de prácticas basadas en la evidencia que podrían alentar sus procesos de recuperación. Una historia de violencia estatal y crisis económicas cíclicas atentaron contra la continuidad de invalorables prácticas comunitarias que, particularmente en Argentina, fueron borradas por mucho tiempo a partir del golpe de estado de 1976.   Este artículo describe el proceso de adaptación cultural para Argentina del programa Illness Management and Recovery llevado a cabo por un equipo conformado por personas usuarias de servicios de salud mental, ex usuarios y profesionales. Esta adaptación se plantea como un puente entre el legado de prácticas comunitarias latinoamericanas en salud mental y las nuevas prácticas basadas en la evidencia que surgen con la incorporación de la voz y la experiencia de las personas usuarias al campo de la salud mental. Finalmente, se incluyen reflexiones sobre la experiencia de adaptación y recomendaciones para la futura implementación local del programa renombrado como “Programa Activo para la Recuperación”. 

Relato de la experiencia en Argentina de la adaptación de un programa estandarizado guiado por la recuperación en salud mental

El concepto de recuperación, su conceptualización y consideración para las prácticas en el campo de la salud mental, pese a su significativo desarrollo a nivel mundial, están pendientes en América Latina. Como consecuencia, se registran demoras para implementar cambios estructurales en la atención especializada y las personas usuarias del sistema de salud mental se ven privadas de prácticas basadas en la evidencia que podrían alentar sus procesos de recuperación. Una historia de violencia estatal y crisis económicas cíclicas atentaron contra la continuidad de invalorables prácticas comunitarias que, particularmente en Argentina, fueron borradas por mucho tiempo a partir del golpe de estado de 1976.   Este artículo describe el proceso de adaptación cultural para Argentina del programa Illness Management and Recovery llevado a cabo por un equipo conformado por personas usuarias de servicios de salud mental, ex usuarios y profesionales. Esta adaptación se plantea como un puente entre el legado de prácticas comunitarias latinoamericanas en salud mental y las nuevas prácticas basadas en la evidencia que surgen con la incorporación de la voz y la experiencia de las personas usuarias al campo de la salud mental. Finalmente, se incluyen reflexiones sobre la experiencia de adaptación y recomendaciones para la futura implementación local del programa renombrado como “Programa Activo para la Recuperación”. 

Targeting Personal Recovery of People With Complex Mental Health Needs: The Development of a Psychosocial Intervention Through User-Centered Design

Long-term admissions in psychiatric facilities often result in a gradual erosion of the identity of people diagnosed with severe mental illnesses (SMIs) into merely "patient." Moreover, experiences of loss often reduced people's sense of purpose. Although regaining a multidimensional identity and a sense of purpose are essential for personal recovery, few interventions specifically address this, while at the same time take people's often considerable cognitive and communicative disabilities into consideration. This study describes the development process of a new intervention through user-centered design (UCD). UCD is an iterative process in which a product (in this case, an intervention) is developed in close cooperation with future users, such that the final product matches their needs. The design process included three phases: an analysis, design, and evaluation phase. In the analysis phase, the "problem" was defined, users' needs were identified, and design criteria were established. In the design phase, the collected information served as input to create a testable prototype using a process of design and redesign, in close collaboration with service users and other stakeholders. This resulted in an intervention entitled "This is Me" (TiM) in which service users, together with a self-chosen teammate, actively engage in new experiences on which they are prompted to reflect. Finally, in the evaluation phase, TiM was implemented and evaluated in a real-life setting. In a small feasibility pilot, we found indications that some people indeed demonstrated increased reflection on their identity during the intervention. Furthermore, TiM seemed to benefit the relationship between the service users and the mental health professionals with whom they underwent the experiences. The pilot also revealed some aspects of the (implementation of) TiM that can be improved. Overall, we conclude that UCD is a useful method for the development of a new psychosocial intervention. The method additionally increased our knowledge about necessary factors in targeting personal recovery for people with complex mental health needs. Moreover, we conclude that TiM is a promising tool for supporting people with SMI in redeveloping a multidimensional identity and a renewed sense of purpose.

Implementing a transdiagnostic sleep and circadian intervention in a community mental health setting: A qualitative process evaluation with community stakeholders

The implementation of evidence-based psychological treatments (EBPTs) may be particularly challenging to accomplish in community mental health settings for individuals with severe mental illness (SMI). Transdiagnostic treatments, or treatments that target a mechanism that underpins multiple mental health problems, may be particularly well-suited to community mental health settings. This study examines community stakeholder perspectives (N = 22) of the Transdiagnostic Sleep and Circadian Intervention (TranS-C) implemented in a community mental health setting in the context of a randomized controlled trial of TranS-C for SMI. The present study aimed to identify barriers and facilitators to the implementation of TranS-C for SMI in a community mental health setting using (1) a deductive theory-based process based on the Framework for Dissemination in Health Services Intervention Research and (2) an inductive thematic analysis process. All deductive themes were identified as both barriers and facilitators to the implementation of EBPTs and TranS-C in this community mental health setting. Seven additional themes were identified through the inductive thematic analysis. A discussion of how the findings are related to prior research, other EBPT implementation, and future TranS-C implementation are included.

Growth and Sustainment of Individual Placement and Support

Many people with serious mental disorders want to work. Individual placement and support (IPS), an evidence-based program that helps such individuals find and maintain jobs of their choice, has spread steadily across the United States (which has more than 1,000 IPS programs) and to at least 19 other countries during the past 20 years. Four factors explain the program's success. First, IPS is client-centered-IPS specialists follow their clients' preferences regarding issues such as type of employment, style of job search, and type of job support needed. Second, research has undergirded IPS's evolution, helping to refine its effectiveness. Third, support from private foundations and federal agencies has helped to foster implementation, research, and dissemination efforts. Fourth, an international learning community has consolidated cooperation among stakeholders and mental health and vocational rehabilitation agencies and has facilitated continuous quality improvement through data sharing and extensive interactions.

Evaluation of an Adaptive Implementation Program for Cognitive Adaptation Training for People With Severe Mental Illness: Protocol for a Randomized Controlled Trial

BACKGROUND

Cognitive Adaptation Training is a psychosocial intervention that focuses on reducing the negative effects of cognitive disorders, especially executive functions such as planning and targeted action. International research has shown that Cognitive Adaptation Training enhances multiple aspects of daily functioning in people with severe mental illnesses. Despite this evidence, implementation of the intervention into routine care remains a challenge.

OBJECTIVE

In this implementation research, a newly developed implementation program based on previous experience and scientific literature, is tested. The primary aim of this research is to assess the effectiveness of the implementation program. The secondary aim of this study is to evaluate the factors that impede or facilitate the implementation of Cognitive Adaptation Training.

METHODS

To test the effectiveness of the implementation program, a multicenter cluster randomized controlled trial was conducted comparing the implementation program to a single training program in four mental health institutions in The Netherlands. Focus groups, semistructured interviews, and questionnaires were used at multiple levels of service delivery (service user, professional, team, organization) to identify factors that may hamper or facilitate implementation. The RE-AIM framework was applied to measure the implementation effectiveness. Following this framework, the primary outcomes were Reach, Intervention Effectiveness, Adoption, Implementation, and Maintenance. These are assessed before, during, and after implementation. The research had a total duration of 14 months, with a follow-up measurement at 14 months. Data will be analyzed using multilevel modeling.

RESULTS

The study was funded in April 2018. Data collection occurred between November 2018 and January 2020. In total, 21 teams of 4 mental health institutions agreed to participate. Data analysis is ongoing and results are expected to be published in December 2020.

CONCLUSIONS

This implementation research may provide important information about the implementation of psychosocial interventions in practice and may result in a program that is useful for Cognitive Adaptation Training, and possibly for psychosocial interventions in general.

TRIAL REGISTRATION

The Netherlands Trial Register (NL7989); https://www.trialregister.nl/trial/7989.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/17412.

Fidelity Scale: From Black Box to Holy Grail

Fidelity scales are indispensable in the pursuit of evidence-based mental healthcare. Without fidelity checks, treatment remains a mysterious black box. The aim of this article is to comment on the studies in this special section, and to discuss some general issues with regard to fidelity assessment. Despite all of their supposed benefits, resistance to fidelity scales persists among mental health practitioners. One way to overcome this resistance is to conduct fidelity assessments in the context of a well-guided learning community. The predictive validity of fidelity scales is considered the single most valuable attribute of these instruments. Research on predictive validity requires large sample sizes, which is difficult to achieve. It should nevertheless not prevent us from rigorously searching for this Holy Grail of fidelity assessment. In addition, fidelity assessment should be placed in a broader perspective. The quality of care for people with severe mental illness cannot be assessed conclusively according to the extent to which separate interventions have been applied with good fidelity. These individuals need access to high-quality treatment and support systems within the community, which can enable them to live their lives as valued citizens. In conclusion, fidelity assessment, both at the level of interventions and systems, contributes to a highly desirable transparency in practice variations within the field of mental healthcare.

Adapted Dialectical Behavior Therapy for Adolescents with a High Risk of Suicide in a Community Clinic: A Pragmatic Randomized Controlled Trial

OBJECTIVE

This study is a pragmatic randomized controlled trial, which compares the effectiveness of an adapted form of Dialectical Behavior Therapy for Adolescents (DBT-A) and treatment as usual plus group sessions (TAU + GS) to reduce suicidal risk for adolescents in a community health mental clinic.

METHOD

Thirty-five adolescents from a community outpatient clinic, with repetitive NSSI alone or with SA over the last 12 months and with current high suicide risk as assessed by the Columbia-Suicide Severity Rating Scale (C-SSRS), were enrolled. Participants were randomly assigned to undergo either DBT-A (n = 18) or TAU + GT (n = 17) treatments over a 16-week period. Primary outcomes were the difference between NSSI and SA recorded during the first 4 weeks and the final 4 weeks of treatment. Secondary outcomes included changes in Children's Global Assessment Scale (C-GAS), Suicidal Ideation Questionnaire (SIQ-JR), and Beck Depression Inventory-II (BDI-II).

RESULTS

Dialectical Behavior Therapy for Adolescents was more effective than TAU + GS at reducing NSSI, use of antipsychotics, and improving C-GAS. No SAs were reported in the two groups at the end of the treatment. Both treatments were equally effective in decreasing SIQ-JR and BDI-II scores.

CONCLUSIONS

These findings support the feasibility and effectiveness of DBT-A for adolescents at high risk of suicide in community settings.

An ethnic-group comparison of caregiver beliefs about early psychotic illness in a UK sample: Implications for evidence-based caregiver interventions

This study aimed to investigate potential ethnic differences in cognitive responses to caregiving in psychosis that might be relevant to the delivery of caregiver interventions for difficulties related to psychosis. We compared cross-sectional outcomes across early-stage caregivers who self-identified as white British (n = 37) and those who self-identified as black African or Caribbean (n = 41) using United Kingdom (UK) census ethnicity criteria. Self-report questionnaires were used to examine caregiver beliefs about psychosis, including the perceived causes, consequences, timeline, the degree of control that patients have over their difficulties, as well as their appraisals of caregiving. Caregivers from black African or Caribbean backgrounds reported a significantly shorter expected duration of illness than white British caregivers. They were also more likely to cite psychosocial causes (e.g., relationship issues), and less likely to cite biological and genetic causes, as their principal explanations for problems. However, overall differences in perceived causes of illness between ethnicities were not significant, despite the power in this sample to detect medium-sized effects. Factors associated with ethnicity may contribute to individual differences in explanatory models of illness and in experiences of caregiving. A degree of sensitivity to the range of views that people might hold about psychosis may help to engage caregivers from diverse ethnic backgrounds.

How community therapists describe adapting evidence-based practices in sessions for youth: Augmenting to improve fit and reach

The study sought to (a) characterize the types and frequency of session-level adaptations made to multiple evidence-based practices (EBPs) and (b) identify therapist-, client-, and session-level predictors of adaptations. Within the community implementation of multiple EBPs, 103 community mental health therapists reported on 731 therapy sessions for 280 clients. Therapists indicated whether they adapted EBPs in specific sessions and described adaptations in open-ended responses. Responses were coded using the Augmenting and Reducing adaptations framework. Therapists reported making adaptations in 59% of sessions. Augmenting adaptations were reported more frequently than Reducing adaptations. Multilevel logistic regression analyses revealed that greater therapist openness to EBPs, younger child age, and presenting problems was associated with Augmenting adaptations. Child presenting problem of externalizing problems predicted fewer Reducing adaptations compared with internalizing problems. This study extends the growing research examining adaptations within the context of the system-driven implementation of multiple EBPs by applying the Augmenting and Reducing adaptation framework to the session-level.

The Family Psychoeducation Fidelity Scale: Psychometric Properties

This study examined psychometric properties and feasibility of the Family Psychoeducation (FPE) Fidelity Scale. Fidelity assessors conducted reviews using the FPE fidelity scale four times over 18 months at five sites in Norway. After completing fidelity reviews, assessors rated feasibility of the fidelity review process. The FPE fidelity scale showed excellent interrater reliability (.99), interrater item agreement (88%), and internal consistency (mean = .84 across four time points). By the 18-month follow-up, all five sites increased fidelity and three reached adequate fidelity. Fidelity assessors rated feasibility as excellent. The FPE fidelity scale has good psychometric properties and is feasible for evaluating the implementation of FPE programs. Trial registration ClinicalTrials.gov Identifier: NCT03271242.

Including culture in programs to reduce stigma toward people with mental disorders in low- and middle-income countries

Stigma is one of the main barriers for the full implementation of mental health services in low- and middle-income countries (LMICs). Recently, many initiatives to reduce stigma have been launched in these settings. Nevertheless, the extent to which these interventions are effective and culturally sensitive remains largely unknown. The present review addresses these two issues by conducting a comprehensive evaluation of interventions to reduce stigma toward mental illness that have been implemented in LMICs. We conducted a scoping review of scientific papers in the following databases: PubMed, Google Scholar, EBSCO, OVID, Embase, and SciELO. Keywords in English, Spanish, and Portuguese were included. Articles published from January 1990 to December 2017 were incorporated into this article. Overall, the studies were of low-to-medium methodological quality-most only included evaluations after intervention or short follow-up periods (1-3 months). The majority of programs focused on improving knowledge and attitudes through the education of healthcare professionals, community members, or consumers. Only 20% (5/25) of the interventions considered cultural values, meanings, and practices. This gap is discussed in the light of evidence from cultural studies conducted in both low and high income countries. Considering the methodological shortcomings and the absence of cultural adaptation, future efforts should consider better research designs, with longer follow-up periods, and more suitable strategies to incorporate relevant cultural features of each community.

Measuring fidelity to behavioural support delivery for smoking cessation and its association with outcomes

BACKGROUND AND AIMS

Behavioural support increases smoking cessation in clinical settings, but effect sizes differ among providers, due possibly to variations in delivery. This study evaluates a measure ('fidelity index') intended to capture fidelity to delivery of content- and interaction-based items of a behavioural support (BS) for smoking cessation and the association of fidelity with quit rates.

METHODS

A fidelity index for scoring the adherence and quality domains of a specific BS intervention, '5As for quit', was developed by classifying the intervention components using the taxonomy of behaviour change techniques. The index was applied to code 154 BS sessions audiotaped among 18 chest clinics in Pakistan to assess their fidelity and explore reliability of coding. The association between intervention fidelity and successful quit achieved by the same providers in a previous study was explored using regression analysis.

RESULTS

The index represented two domains: adherence to delivery of content-based activities of 5As (37 items) and quality of interaction-based activities (eight items). The intercoder reliability was good for content-based (average Krippendorff's α = 0.80) and moderate for interaction-based (average Krippendorff's α = 0.66) items. Approximately 70% (intraclass correlation coefficient: adherence scores = 0.72, quality scores = 0.71) of variation in BS delivery was contributed by providers, which increased to 97% (g-coefficient: adherence scores = 0.973, quality scores = 0.974) after accounting for other sources of variation. Higher quit rates were positively associated with average quality scores [risk ratio = 2.15; 95% confidence interval (CI) = 1.43-3.24], but negatively associated with average adherence scores (risk ratio = 0.55; 95% CI = 0.40-0.77) within services.

CONCLUSIONS

The fidelity index is a reliable measure for quantifying intervention fidelity of delivering smoking cessation behavioural support. Recommended revisions of the fidelity index include incorporation of additional interaction-based items, such as the relational techniques used in motivational interviewing.

File audit to assess sustained fidelity to a recovery and wellbeing oriented mental health service model: an Australian case study

Background

Over the past decade there has been increasing attention to implementing recovery-oriented approaches within mental health service practice and enhancing fidelity to such approaches. However, as is often the case with evidence-based practices, less attention has been paid to the sustainability of recovery-oriented approaches over time. This study sought to investigate whether fidelity to a recovery-oriented practice framework – the Collaborative Recovery Model could be sustained over time.

Method

The study setting was an Australian community managed mental health organisation. A file audit of consumer support plans was undertaken using the Goal and Action Plan Instrument for Quality audit tool (GAP-IQ). The audit tool assessed 17 areas for quality. Consumers (n = 116) from a large community managed mental health organisation participated in the study. Sustained fidelity to the Collaborative Recovery Model (CRM) was determined by comparing results from the file audit to a similar audit conducted 3 years earlier.

Results

The file audit revealed a significant increase in fidelity to CRM practices between 2011 and 2014. Fidelity to individual audit items that comprise the GAP-IQ was also found to significantly increase across 16 of the 17 GAP-IQ audit items, with the exception of the ‘Action Plan Review’ audit item.

Conclusions

A comparison of file audit data across different time points within the same setting can provide useful feedback about whether or not a practice is being sustained over time. Although fidelity increased overtime the study design does not allow conclusions that training and coaching practices implemented by the organisation were responsible.

Assessing the Fidelity of Evidence-Based Practices: History and Current Status of a Standardized Measurement Methodology

Evidence-based practices are effective only when implemented faithfully. This paper explicates the history, standardization, and methods for developing and validating measures of fidelity. We overviewed the past 20 years of developing fidelity measures, summarized standardization of the development procedures, and described needed psychometric assessments. Fidelity assessment has become the sine qua non of implementation, technical assistance, and research on evidence-based practices. Researchers have established standardized procedures for scale development and psychometric testing. Widescale use of fidelity measurement remains challenging. The implementation of evidence-based practice and the development and validation of fidelity measures are interdependent. International improvements of mental health care will require attention to both.

Rising co-payments coincide with unwanted effects on continuity of healthcare for patients with schizophrenia in the Netherlands

BACKGROUND

Co-payments, used to control rising costs of healthcare, may lead to disruption of appropriate outpatient care and to increases in acute crisis treatment or hospital admission in patients with schizophrenia. An abrupt rise in co-payments in 2012 in the Netherlands offered a natural experiment to study the effects of co-payments on continuity of healthcare in schizophrenia.

METHODS

Retrospective longitudinal registry-based cohort study. Outcome measures were (i) continuity of elective (planned) psychiatric care (outpatient care and/or antipsychotic medication); (ii) acute psychiatric care (crisis treatment and hospital admission); and (iii) somatic care per quarter of the years 2009-2014.

RESULTS

10 911 patients with schizophrenia were included. During the six-year follow-up period the level of elective psychiatric outpatient care (-20%); and acute psychiatric care (-37%) decreased. Treatment restricted to antipsychotic medication (without concurrent outpatient psychiatric care) increased (67%). The use of somatic care also increased (24%). Use of acute psychiatric care was highest in quarters when only antipsychotic medication was received. The majority (59%) of patients received continuous elective psychiatric care in 2009-2014. Patients receiving continuous care needed only half the acute psychiatric care needed by patients not in continuous care. On top of these trends time series analysis (ARIMA) showed that the abrupt rise in co-payments from 2012 onwards coincided with significant increases in stand-alone treatment with antipsychotic medication and acute psychiatric care.

CONCLUSIONS

The use of psychiatric care decreased substantially among a cohort of patients with schizophrenia. The high rise in co-payments from 2012 onwards coincided with significant increases in stand-alone treatment with antipsychotic medication and acute psychiatric care.

A site visit protocol for assessing recovery promotion at the program level: An example from the Veterans Health Administration

OBJECTIVE

A site visit protocol was developed to assess recovery promotion in the organizational climate and culture of programs for veterans with serious mental illnesses.

METHOD

The protocol was pilot-tested in 4 programs: 2 that had scored high on the pilot version of a staff survey measure of program-level recovery promotion and 2 that had scored low. Two-person teams conducted onsite visits and assigned global and organizational domain ratings. Interrater agreement was assessed by examining adjacent agreement and computing weighted kappa.

RESULTS

The on-site protocol had good interrater agreement and discriminated between sites that scored high and low on the staff survey.

CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

This site visit protocol and procedure shows promise for evaluating recovery promotion in milieu-based programs. After further refinement of this tool, adaptations could be developed for accreditation protocols or for program self-assessment and quality improvement efforts. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Barriers and Facilitators to Implementing a Short-Term Transdiagnostic Mental Health Treatment for Homeless Persons

Despite the significant mental health needs and comorbidity in homeless individuals, there is a "science-practice gap" between the available evidence-based treatments (EBTs) and their lack of use in community health centers servicing homeless populations. To address this gap, it is imperative to evaluate and attend to the contextual factors that influence the implementation process of EBTs before their integration into routine care. The study aims to evaluate the barriers and facilitators to implementing a transdiagnostic EBT in a community health center serving homeless individuals. The results of the thematic analyses (7 focus groups, 67 participants) yielded 8 themes for barriers and 10 themes for facilitators to implementation. The findings of the current study highlight common tensions faced by community programs and clinicians when working toward integrating EBTs across different types of populations, and those unique to homeless persons. Results can inform subsequent strategies used in implementing EBTs.

Utilisation et enjeux des données clinico-administratives dans le domaine de la santé mentale et de la dépendance

Les banques de données clinico-administratives sont des outils clés pour la prise de décision publique en santé. Pour soutenir la gestion des services, plusieurs banques sont disponibles s’intéressant aux besoins des populations et aux ressources disponibles, tout en intégrant des indicateurs de performance. Depuis les années 2000, des efforts considérables ont été menés afin de consolider les données et développer des outils visant à mieux surveiller l’état de santé des populations ou la performance du système sociosanitaire. Dans le cadre du congrès annuel de l’Association francophone pour le savoir (ACFAS), qui s’est tenu à l’Université McGill en 2017, un colloque a été organisé pour débattre de leur exploitation en santé mentale et en dépendance. Le colloque a intégré une discussion d’experts qui se sont entretenus afin d’identifier les principales banques clinico-administratives, l’ampleur de leur utilisation, leurs limites et les solutions à développer pour les optimiser afin de mieux soutenir la gestion des services. Cet article vise à résumer le contenu de ces discussions. Bien que les banques comportent des forces importantes, dont un potentiel élevé de généralisation de l’information, elles présentent des limites se rapportant surtout à leur capacité à répondre aux besoins, à des enjeux de qualité et de validation, ainsi que d’accessibilité. Diverses recommandations ont été émises pour améliorer leur gestion et optimiser leur impact, dont leur conservation et traitement dans un organisme autonome et hautement accessible, et un changement sociétal de culture favorisant l’évaluation de la performance afin d’améliorer les pratiques et de mieux monitorer les résultats de santé.

Attitudes of mental health providers towards adoption of evidence-based interventions: relationship to workplace, staff roles and social and psychological factors at work

Background

Gaining insight into factors influencing the adoption of evidence-based interventions (EBI) is essential to ensuring their sustainability in the mental healthcare setting. This article describes 1) differences between professional staff roles in attitudes towards EBI and 2) individual and organizational predictors of attitudes towards adopting EBI.

Methods

The participants were psychologists and psychiatric nurses (N = 792). Student t-tests were used to investigate group differences of global attitude scores on the Evidence-based Practice Attitude Scale-36 (EBPAS-36). A confirmatory factor analysis (CFA) of the EBPAS-36 measurement model, and a principal component analysis (PCA) of the factor scores were used to obtain attitudinal components for the subsequent hierarchical regression analyses.

Results

Three second-order attitudinal components were retained and named: professional concern, attitudes related to work conditions and requirements, and attitudes related to fit and preferences. Nurses’ global attitudinal scores were more positive than those of psychologists, while clinicians had less positive global attitudinal scores than non-clinicians. Hierarchical regression analysis showed that provider demographic, social and psychological factors in the workplace and staff role predicted attitudes towards adopting EBI, e.g. male gender, older age and working in private practice predicted more negative global attitudes, while working in academia, experiencing social support from colleagues and empowering leadership predicted more positive global attitudes to adopt EBI. The prediction outcomes for the specific attitudinal components are presented, as well.

Conclusion

The findings suggest that implementation efforts may benefit from being tailored to the different needs and values of the affected professionals, including the role of the context they operate within. Implications with a special emphasis on training efforts and organizational development are discussed.

Variation in seclusion rates across New Zealand's specialist mental health services: Are sociodemographic and clinical factors influencing this?

Rates of seclusion vary across New Zealand's publicly funded district health board (DHB) adult mental health inpatient services as indicated by national data. Anecdotally, this variation has been attributed to a range of factors directly relating to the people admitted to acute inpatient services. This study examined the extent to which variation in seclusion rates could be explained by the sociodemographic and clinical differences between populations admitted into adult mental health inpatient services. Retrospective data were obtained from the Programme for the Integration of Mental Health Data (PRIMHD). A logistic regression model was fitted to these data, with seclusion (yes/no) as the dependent variable and DHB groups as the independent variable. The DHBs were classified into four groups based on their seclusion rates. The model adjusted for ethnicity, age, number of bed nights, total Health of the Nation Outcome Scales (HoNOS) scores, and compulsory treatment status. Odds ratios remained virtually unchanged after adjustment for sociodemographic and clinical factors. People admitted to DHB Group 4 (highest secluding DHBs) were 11 times more likely to be secluded than people in Group 1 (lowest secluding DHBs), adjusted OR = 11.1, 95% CI [7.5,16.4], P < 0.001. Results indicate DHB variation in seclusion rates cannot be attributed to the sociodemographic and clinical factors of people admitted into DHB adult mental health inpatient services. Instead, this variation may be explained by differences in service delivery models and practice approaches. A model of system improvements aimed at reducing seclusion is discussed.

Therapist Reports of EBP Client Engagement Challenges in Sessions with Diverse Youth and Families in Community Mental Health Settings

BACKGROUND

The implementation of evidence-based practices (EBPs) in community settings appears to result in reduced benefit relative to controlled trials. This difference in outcomes may be attributable in part to engagement challenges therapists encounter when delivering EBPs to low-income ethnic minority youth and families.

OBJECTIVE

The current study sought to identify therapist, client, and session characteristics associated with therapist-reported engagement challenges in therapy sessions, as well the associations between two types of client engagement challenges and therapists' self-reported ability to deliver the EBP in sessions within a system-driven implementation in public children's mental health services.

METHOD

One hundred and three therapists reported on two types of engagement challenges-Limited Client Engagement and Expressed Client Concerns-in 702 sessions with 274 clients.

RESULTS

Results indicated that therapists reported a higher frequency of Limited Client Engagement in sessions with male clients and in sessions where the youth was present, and by therapists with smaller caseloads. No variables significantly predicted Expressed Client Concerns. Both types of engagement challenges were negatively associated with therapists' report of their ability to carry out intended activities in the same session.

CONCLUSIONS

Findings suggest that therapists may benefit from learning strategies to address these two distinct types of engagement challenges encountered in implementation of EBPs with diverse families in community settings.

Complex Interventions and Interorganisational Relationships: Examining Core Implementation Components of Assertive Community Treatment

Introduction:

There is increasing interest in implementing evidence-based integrated models of care in community-based mental health service systems. Assertive Community Treatment (ACT) is seen as an attractive, and at the same time challenging, model to implement in sectored service settings. This study investigates the implementation process of such an initiative.

Methods:

Interviews were conducted with ACT team members, the process leader, steering group members, and collaboration partners. The “Sustainable Implementation Scale” helped to identify critical implementation components, and these were further explored using the qualitative interview data. The “Tool for Measuring Assertive Community Treatment” addressed programme fidelity, and the initiative’s sustainability was assessed.

Results:

High-fidelity implementation of ACT in a sectored service setting is possible. Prominent components that facilitated implementation were careful preparations, team members’ characteristics, and efforts by the process leader and the steering group to improve networking. Implementation was hampered by conflicting goals among the involved authorities and a mismatch between the ACT model’s characteristics and existing organisational traditions and regulations.

Discussion and Conclusions:

Reducing the uncertainty caused by conflicting goals is an important step in improving the implementation of ACT. In order to facilitate implementation, the goals, regulations, and availability of resources should be aligned horizontally and vertically through the involved organisations.