Factors impacting the implementation of a psychoeducation intervention within the mental health system: a multisite study using the consolidation framework for implementation research

The Helping Hand in Ukraine: feasibility and potential impact

BACKGROUND

New services are needed to prevent the mental health consequences of the war in Ukraine. Ten adolescents self-recruited to use and evaluate the Ukrainian version of the Helping Hand (HH) in Odesa, Ukraine. From April to June 2023, they participated in a 10-session group program where they played the cognitive behavioral game app, shared stories, and engaged in activities to enhance their coping skills.

METHODS

A mixed-method, quantitative-qualitative design was used to get insight into the feasibility and potential impact of the HH on Ukrainian adolescents' mental health and well-being during the war. A questionnaire to the adolescents assessed the feasibility of the intervention; anxiety and depression symptoms were assessed before and after the intervention by a standardized and validated adolescent-completed questionnaire. An interview with the psychologist who implemented the intervention was used to interpret the data completed by the adolescents.

RESULTS

Eight of 10 adolescents completed the HH intervention, and the psychologist found the HH helpful and culturally appropriate. The average anxiety and depression symptoms decreased from before the intervention (M = 20.4) to after (M = 15.0), showing a moderate effect size.

CONCLUSION

The results indicated that the HH has a high potential to prevent mental health consequences in Ukraine.

Decoding Suicide Decedent Profiles and Signs of Suicidal Intent Using Latent Class Analysis

Importance

Suicide rates in the US increased by 35.6% from 2001 to 2021. Given that most individuals die on their first attempt, earlier detection and intervention are crucial. Understanding modifiable risk factors is key to effective prevention strategies.

Objective

To identify distinct suicide profiles or classes, associated signs of suicidal intent, and patterns of modifiable risks for targeted prevention efforts.

Design, Setting, and Participants

This cross-sectional study used data from the 2003-2020 National Violent Death Reporting System Restricted Access Database for 306 800 suicide decedents. Statistical analysis was performed from July 2022 to June 2023.

Exposures

Suicide decedent profiles were determined using latent class analyses of available data on suicide circumstances, toxicology, and methods.

Main Outcomes and Measures

Disclosure of recent intent, suicide note presence, and known psychotropic usage.

Results

Among 306 800 suicide decedents (mean [SD] age, 46.3 [18.4] years; 239 627 males [78.1%] and 67 108 females [21.9%]), 5 profiles or classes were identified. The largest class, class 4 (97 175 [31.7%]), predominantly faced physical health challenges, followed by polysubstance problems in class 5 (58 803 [19.2%]), and crisis, alcohol-related, and intimate partner problems in class 3 (55 367 [18.0%]), mental health problems (class 2, 53 928 [17.6%]), and comorbid mental health and substance use disorders (class 1, 41 527 [13.5%]). Class 4 had the lowest rates of disclosing suicidal intent (13 952 [14.4%]) and leaving a suicide note (24 351 [25.1%]). Adjusting for covariates, compared with class 1, class 4 had the highest odds of not disclosing suicide intent (odds ratio [OR], 2.58; 95% CI, 2.51-2.66) and not leaving a suicide note (OR, 1.45; 95% CI, 1.41-1.49). Class 4 also had the lowest rates of all known psychiatric illnesses and psychotropic medications among all suicide profiles. Class 4 had more older adults (23 794 were aged 55-70 years [24.5%]; 20 100 aged ≥71 years [20.7%]), veterans (22 220 [22.9%]), widows (8633 [8.9%]), individuals with less than high school education (15 690 [16.1%]), and rural residents (23 966 [24.7%]).

Conclusions and Relevance

This study identified 5 distinct suicide profiles, highlighting a need for tailored prevention strategies. Improving the detection and treatment of coexisting mental health conditions, substance and alcohol use disorders, and physical illnesses is paramount. The implementation of means restriction strategies plays a vital role in reducing suicide risks across most of the profiles, reinforcing the need for a multifaceted approach to suicide prevention.

Evidence-based psychosocial interventions in schizophrenia: a critical review

PURPOSE OF REVIEW

Schizophrenia Spectrum Disorders (SSD) are severe conditions that frequently produce significant impairment in cognitive performance, social skills and psychosocial functioning. As pharmacological treatment alone often provides only limited improvements on these outcomes, several psychosocial interventions are employed in psychiatric rehabilitation practice to improve of real-world outcomes of people living with SSD: the present review aims to provide a critical overview of these treatments, focusing on those that show consistent evidence of effectiveness.

RECENT FINDINGS

Several recent systematic reviews and meta-analyses have investigated in detail the acceptability, the effectiveness on several specific outcomes and moderators of response of different psychosocial interventions, and several individual studies have provided novel insight on their implementation and combination in rehabilitation practice.

SUMMARY

Cognitive remediation, metacognitive training, social skills training, psychoeducation, family interventions, cognitive behavioral therapy, physical exercise and lifestyle interventions, supported employment and some other interventions can be fully considered as evidence-based treatments in SSD. Psychosocial interventions could be of particular usefulness in the context of early intervention services. Future research should focus on developing newer interventions, on better understanding the barriers and the facilitators of their implementation in clinical practice, and exploring the opportunities provided by novel technologies.

Psychoeducational interventions for people living with chronic communicable disease: a systematic review

OBJECTIVE

Psychoeducation is increasingly recognised for its value in facilitating adaption to a chronic disease diagnosis. This study aimed to synthesise available literature on the psychoeducation interventions available to adults living with chronic communicable disease.

METHODS

PubMed, CINAHL, Embase, SocINDEX, PsycINFO and PsycArticles were systematically searched up to May 2023. Peer-reviewed studies, published in English, investigating the impact of psychoeducational interventions on adults living with chronic communicable disease were included, across a range of outcome measures. Narrative synthesis was performed. The Effective Public Health Practice Project tool and Critical Appraisal Skills Programme tool were used to assess risk of bias.

RESULTS

In total, 22 studies were included in the review. The majority (n=16) of study populations focused on people living with HIV, followed by hepatitis C (n=5) and genital herpes (n=1). Interventions were delivered online (n=2), via telephone (n=1) and in-person (n=19). The majority of interventions were delivered in group sessions (n=16) and studies emphasised the value of group cohesion for social support, encouraging participants to share their own knowledge in addition to standard didactic presentations. Four studies facilitated peer-led delivery of the psychoeducation. Studies aiming to improve psychological well-being were beneficial in reducing depressive symptoms and/or emotional distress or showed improvement in the participant group overall. There was some evidence to suggest psychoeducation can improve readiness to attend treatment and medication adherence.

CONCLUSION

The findings of this review highlight potential benefits of psychoeducation but indicate more robust clinical trials will be required to examine their effectiveness and elucidate the mechanisms by which they best operate. Future interventions incorporating a broader focus on resilience enhancement and coping skills specific to stigmatisation could more comprehensively serve the needs of adults living with chronic communicable disease, particularly with HIV. The role of peer support in group psychoeducation merits further exploration.

PROSPERO REGISTRATION NUMBER

CRD42021243058.

Perspectives of key informants before and after implementing UPSIDES peer support in mental health services: qualitative findings from an international multi-site study

BACKGROUND

Peer support is an essential part of recovery-oriented care worldwide. Contextual factors have an impact on the implementation of peer support work. However, research has paid little attention to similarities and differences of implementation factors in settings varying by income-level and cultural values. The aim of this study is to assess the factors influencing the implementation of a peer support intervention across study sites in low-, middle- and high-income countries in line with the Consolidation Framework for Implementation Research (CFIR).

METHOD

6 focus groups with a total of 54 key informants with relevant contextual (organisational) knowledge regarding implementation facilitators and barriers were conducted at six study sites Ulm and Hamburg (Germany), Butabika (Uganda), Dar es Salaam (Tanzania), Be'er Sheva (Israel), and Pune (India) before and 1.5 years after the start of UPSIDES peer support. Transcripts were analysed using qualitative content analysis.

RESULTS

Across study sites key informants reported benefits of peer support for service users and peer support workers as implementation facilitators. At study sites with lower resources, reduced workload for mental health workers and improved access to mental health services through peer support were perceived as implementation facilitators (CFIR Domain 1: Intervention characteristics). The degree of engagement of mental health workers (CFIR Domain 3: Inner Setting/Domain 4: Individuals involved) varied across study sites and was seen either as a barrier (low engagement) or a facilitator (high engagement). Across study sites, adequate training of peer support workers (CFIR Domain 5: Implementation process) was seen as animplementation facilitator, while COVID-19 as well as low resource availability were reported as implementation barriers (CFIR Domain 2: Outer setting).

CONCLUSIONS

This study highlights the importance of considering contextual factors when implementing peer support, including previous experience and perceived benefits. Particular attention should be given to organisational benefits such as workload reduction and the allocation of sufficient resources as key drivers in LMICs. In HICs, the potential of organisational benefits for successful implementation should be further investigated and promoted.

Psychosocial interventions for carers of people with severe mental and substance use disorders: a systematic review and meta-analysis

BACKGROUND

Severe mental disorders - such as schizophrenia, bipolar disorder, and substance use disorders - exert a negative impact not only on affected people but also on their carers. To support carers of people with severe mental disorders, several psychosocial interventions have been developed.

METHODS

This systematic review and meta-analysis aimed to assess whether psychosocial interventions for carers of persons with schizophrenia, bipolar disorder, or substance use disorders produce benefit/harm with respect to a series of outcomes - including subjective and objective burden, depressive symptoms, well-being/quality of life, sleep, skills/knowledge, self-efficacy, physical health - as compared to standard support/support as usual or other control conditions.

RESULTS

In carers of persons with schizophrenia, psychoeducational interventions were associated with significant improvement in personal burden, well-being, and knowledge about the illness; and a supportive-educational intervention with an improvement in personal burden. In carers of persons with bipolar disorder, psychoeducational interventions were associated with significant improvement in personal burden and depressive symptoms; family-led supportive interventions with an improvement in family burden; family-focused intervention and online "mi.spot" intervention with a significant reduction in depressive symptoms. Psychosocial interventions used for carers of persons with substance use disorders were found to be overall effective on the level of well-being, but the low number of trials did not allow detection of differences between the various psychosocial interventions.

CONCLUSIONS

The quality of the evidence ranged from very low to moderate, suggesting the need for further better-quality research.

Facilitators and barriers to implementation of suicide prevention interventions: Scoping review

We know that suicide is preventable, yet hundreds of thousands of people still die due to suicide every year. Many interventions were proven to be effective, and dozens of others showed promising results. However, translating these interventions into new settings brings several challenges. One of the crucial obstacles to success is not anticipating possible barriers to implementation nor enhancing possible benefits of factors facilitating the implementation. While we witnessed great support for suicide prevention activities globally in the past years, implementation barriers and facilitating factors are yet to be comprehensively mapped to help implementation activities worldwide. This scoping review maps current knowledge on facilitators and barriers to the implementation of suicide prevention interventions while using the Consolidated Framework for Implementation Research (CFIR) for classification. We included 64 studies. Barriers and facilitators were most commonly identified in the outer setting CFIR domain, namely in the sub-domain of patient needs and resources, which refers to the way in which these needs and resources are reflected by the reviewed interventions. The second most saturated CFIR domain for facilitators was intervention characteristics, where relative advantage, adaptability and cost of intervention sub-domains were equally represented. These sub-domains refer mostly to how the intervention is perceived by key stakeholders, to what extent it can be tailored to the implementation context and how much it costs. While intervention characteristics domain was the second most common also for barriers, the complexity sub-domain referring to high perceived difficulty of implementation was the most frequently represented. With reference to the results, we recommend adapting interventions to the needs of the target groups. Furthermore, carefully selecting the intervention to suit the target context concerning their adaptability, costs and complexity is vital for a successful implementation. Further implications for practice and research are discussed.

Contextual Factors Affecting Implementation of Pediatric Quality Improvement Programs

OBJECTIVE

Context is a critical determinant of the effectiveness of quality improvement programs. We assessed the role of contextual factors in influencing the efforts of 5 diverse quality improvement projects as part of the Pediatric Quality Measure Program (PQMP) directed by the Agency for Health Care Research and Quality.

METHODS

We conducted a mixed methods study of 5 PQMP grantees involving semistructured interviews followed by structured worksheets to identify influential contextual factors. Semistructured interviews and worksheets were completed between August and October 2020. Participants were comprised of PQMP grantee teams (2-4 team members per team for a total of 15 participants). Coding and analysis was based on the Tailored Implementation for Chronic Diseases (TICD) framework.

RESULTS

Despite heterogeneity in the process and outcome targets of the PQMP initiatives, professional interactions, incentives and resources, and capacity for organizational change were the domains most commonly identified as influential across the grantees. While social, political, and legal factors was not commonly referenced as an important domain, payer or funder policies (a factor within this domain) was highlighted as one of the most influential factors. Overall, the incentives and resources domain was identified as the most influential.

CONCLUSIONS

We found that using a determinant framework, such as the TICD, is valuable in facilitating comparisons across heterogeneous projects, allowing us to identify key contextual factors influencing the implementation of pediatric quality measures across a diverse range of clinical topics and settings. Future quality improvement work should account for this and include resources to support infrastructure development in addition to program implementation.

Factors Influencing Attendees' Engagement with Group Psychoeducation: A Multi-stakeholder Perspective

Few studies have explored the problem of engagement in relation to group psychoeducation from a multi-site and multi-stakeholder perspective. The aim of the study was to explore the factors influencing service user and family engagement with group psychoeducation programmes. The study design was qualitative descriptive. Data were collected through individual and focus group interviews with key stakeholders (n = 75) involved with the programme within 14 mental health sites in the Republic of Ireland. Enablers and barriers to engagement were identified at participant, provider, programme and organization level. Motivated participants and engaged clinicians, peer co-facilitation and support, and skilled and responsive facilitators were some of the factors which enhanced engagement. Barriers to engagement included readiness among participants, concerns related to stigma and confidentiality, desire to distance oneself from mental health services, a lack of support for programme participation within families, group discomfort, the time and length of the programme, issues with transport, visibility of the programme, and structural supports for clinicians. Findings from the study illustrate the multifaceted nature of engagement as well as provide a greater understanding of the multifactorial influences on engagement. Strategies to enhance engagement should therefore reflect a multipronged approach. At the outset of programme implementation, organizations should address their readiness to engage, conduct local needs assessments to anticipate individuals’ needs and plan accordingly in order to maximize engagement, and bolster facilitators’ engagement skills through the provision of training and mentoring opportunities.

Implementation of a web-based computerised decision support system for Community Mental Health Services using national electronic health records (Preprint)

Background

A high proportion of patients with severe mental illness relapse due to nonadherence to psychotropic medication. In this paper, we use the normalization process theory (NPT) to describe the implementation of a web-based clinical decision support system (CDSS) for Community Mental Health Services (CMHS) called Actionable Intime Insights or AI². AI² has two distinct functions: (1) it provides an overview of medication and treatment history to assist in reviewing patient adherence and (2) gives alerts indicating nonadherence to support early intervention.

Objective

Our objective is to evaluate the pilot implementation of the AI² application to better understand the challenges of implementing a web-based CDSS to support medication adherence and early intervention in CMHS.

Methods

The NPT and participatory action framework were used to both explore and support implementation. Qualitative data were collected over the course of the 14-month implementation, in which researchers were active participants. Data were analyzed and coded using the NPT framework. Qualitative data included discussions, meetings, and work products, including emails and documents.

Results

This study explores the barriers and enablers of implementing a CDSS to support early intervention within CMHS using Medicare data from Australia’s national electronic record system, My Health Record (MyHR). The implementation was a series of ongoing negotiations, which resulted in a staged implementation with compromises on both sides. Clinicians were initially hesitant about using a CDSS based on MyHR data and expressed concerns about the changes to their work practice required to support early intervention. Substantial workarounds were required to move the implementation forward. This pilot implementation allowed us to better understand the challenges of implementation and the resources and support required to implement and sustain a model of care based on automated alerts to support early intervention.

Conclusions

The use of decision support based on electronic health records is growing, and while implementation is challenging, the potential benefits of early intervention to prevent relapse and hospitalization and ensure increased efficiency of the health care system are worth pursuing.