Patient Satisfaction and Recommendations for Delivering a Group-Based Intensive Outpatient Program via Telemental Health During the COVID-19 Pandemic: Cross-sectional Cohort Study

BACKGROUND

Although group-based intensive outpatient programs (IOPs) are a level of care commonly utilized by adults with serious mental illness, few studies have examined the acceptability of group-based IOPs that required rapid transition to a telemental health (TMH) format during the COVID-19 pandemic.

OBJECTIVE

The aim of this study was to evaluate patient satisfaction and future recommendations for a group-based IOP that was transitioned to a TMH format during the COVID-19 pandemic.

METHODS

A 17-item patient satisfaction questionnaire was completed by patients at discharge and covered 3 areas: IOP TMH satisfaction, future recommendations, and video technology challenges. Descriptive and content analyses were conducted for the quantitative and open-ended questions, respectively.

RESULTS

A total of 76 patients completed the program in 2020. A subset of patients (n=40, 53%) responded to the survey at program discharge. The results indicated that the patients were satisfied overall with the TMH program format; 50% (n=20) of the patients preferred the program continue offering the TMH format, and the rest preferred returning to in-person formats after the pandemic. The patients indicated the elements of the program that they found most valuable and provided recommendations for future program improvement.

CONCLUSIONS

Overall, adults with serious mental illness reported high satisfaction with the group-based IOP delivered via TMH. Health care systems may want to consider offering both TMH and in-person formats regardless of the state of the pandemic. Patients' feedback on future improvements should be considered to help ensure long-term success.

Perinatal Mood and Anxiety Disorder Management in Multicenter Community Practices: Clinicians' Training, Current Practices and Perceived Strategies to Improve Future Implementation

Background:

This study aimed to explore clinicians’ perspectives on the current practice of perinatal mood and anxiety disorder (PMAD) management and strategies to improve future implementation.

Methods:

This study had a cross-sectional, descriptive design. A 35-item electronic survey was sent to clinicians (N = 118) who treated perinatal women and practiced at several community clinics at an academic medical center in the United States.

Results:

Among clinicians who provided care for perinatal women, 34.7% reported never receiving PMAD management training and 66.3% had less than 10 years of experience. Out of 10 patients who reported psychiatric symptoms, 47.8% of clinicians on average reported providing PMAD management to 1 to 3 patients and 40.7% noted that they conducted screening only when patient expresses PMAD symptoms. Suggested future improvements were providing training, developing a referral list, and establishing integrated behavioral health services.

Conclusions:

Results from this study indicated that while PMAD screening and management was implemented, improvements are warranted to meet established guidelines. Additionally, clinicians endorsed providing PMAD management to a small percentage of perinatal patients. Suggested strategies to increase adoption and implementation of PMAD management should be explored to improve access to behavioral health services for perinatal women.

Rapid Adoption and Implementation of Telehealth Group Psychotherapy During COVID 19: Practical Strategies and Recommendations

Behavioral health services have been tasked with rapidly adopting and implementing teletherapy during the SARS-CoV-2/COVID-19 pandemic to assure patient and staff safety. Existing teletherapy guidelines were developed prior to the pandemic and do not capture the nuances of rapidly transitioning in-person individual and group-based treatments to a teletherapy format. In this paper, we describe our approach to quickly adapting to a teletherapy technology platform for an intensive outpatient program (IOP) guided by cognitive and behavioral modular principles for adults with serious mental illness. A review of existing guidelines was conducted and the staged approach for teletherapy implementation (Muir et al., 2020) was selected as the most appropriate model for our organizational context. We describe the most pertinent implementation strategies and report our preliminary findings detailing the feasibility of IOPs delivered via telehealth. This model of rapid teletherapy implementation offers practical clinical guidelines for administrators and clinicians seeking to transition traditional in-person behavioral health services to a teletherapy format.

A systematic review of measures of implementation players and processes: Summarizing the dearth of psychometric evidence

Background:

Measurement is a critical component for any field. Systematic reviews are a way to locate measures and uncover gaps in current measurement practices. The present study identified measures used in behavioral health settings that assessed all constructs within the Process domain and two constructs from the Inner setting domain as defined by the Consolidated Framework for Implementation Research (CFIR). While previous conceptual work has established the importance social networks and key stakeholders play throughout the implementation process, measurement studies have not focused on investigating the quality of how these activities are being carried out.

Methods:

The review occurred in three phases: Phase I, data collection included (1) search string generation, (2) title and abstract screening, (3) full text review, (4) mapping to CFIR-constructs, and (5) “cited-by” searches. Phase II, data extraction, consisted of coding information relevant to the nine psychometric properties included in the Psychometric And Pragmatic Rating Scale (PAPERS). In Phase III, data analysis was completed.

Results:

Measures were identified in only seven constructs: Structural characteristics ( n = 13), Networks and communication ( n = 29), Engaging ( n = 1), Opinion leaders ( n = 5), Champions ( n = 5), Planning ( n = 5), and Reflecting and evaluating ( n = 5). No quantitative assessment measures of Formally appointed implementation leaders, External change agents, or Executing were identified. Internal consistency and norms were reported on most often, whereas no studies reported on discriminant validity or responsiveness. Not one measure in the sample reported all nine psychometric properties evaluated by the PAPERS. Scores in the identified sample of measures ranged from “-2” to “10” out of a total of “36.”

Conclusions:

Overall measures demonstrated minimal to adequate evidence and available psychometric information was limited. The majority were study specific, limiting their generalizability. Future work should focus on more rigorous measure development and testing of currently existing measures, while moving away from creating new, single use measures.

Plain Language Summary:

How we measure the processes and players involved for implementing evidence-based interventions is crucial to understanding what factors are helping or hurting the intervention’s use in practice and how to take the intervention to scale. Unfortunately, measures of these factors—stakeholders, their networks and communication, and their implementation activities—have received little attention. This study sought to identify and evaluate the quality of these types of measures. Our review focused on collecting measures used for identifying influential staff members, known as opinion leaders and champions, and investigating how they plan, execute, engage, and evaluate the hard work of implementation. Upon identifying these measures, we collected all published information about their uses to evaluate the quality of their evidence with respect to their ability to produce consistent results across items within each use (i.e., reliable) and if they assess what they are intending to measure (i.e., valid). Our searches located over 40 measures deployed in behavioral health settings for evaluation. We observed a dearth of evidence for reliability and validity and when evidence existed the quality was low. These findings tell us that more measurement work is needed to better understand how to optimize players and processes for the purposes of successful implementation.

Feasibility and Initial Outcomes of a Group-Based Teletherapy Psychiatric Day Program for Adults With Serious Mental Illness: Open, Nonrandomized Trial in the Context of COVID-19

BACKGROUND

In the context of the COVID-19 pandemic, many behavioral health services have transitioned to teletherapy to continue delivering care for patients with mental illness. Studies that evaluate the outcome of this rapid teletherapy adoption and implementation are pertinent.

OBJECTIVE

This single-arm, nonrandomized pilot study aimed to assess the feasibility and initial patient-level outcomes of a psychiatric transitional day program that switched from an in-person group to a video teletherapy group during the COVID-19 pandemic.

METHODS

Patients with transdiagnostic conditions who were at risk of psychiatric hospitalization were referred to the Adult Transitions Program (ATP) at a large academic medical center in the United States. ATP was a 3-week intensive outpatient program that implemented group teletherapy guided by cognitive and behavioral principles delivered daily for 3 hours per day. Feasibility was assessed via retention, attendance rate, and rate of securing aftercare appointments prior to ATP discharge. Patients completed standardized patient-reported outcome measures at admission and discharge to assess the effectiveness of the program for improving quality of mental health, depression, anxiety, and suicide risk.

RESULTS

Patients (N=76) started the program between March and August of 2020. Feasibility was established, with 70 of the 76 patients (92%) completing the program and a mean attendance of 14.43 days (SD 1.22); also, 71 patients (95%) scheduled at least one behavioral health aftercare service prior to ATP discharge. All patient-level reported outcomes demonstrated significant improvements in depression (95% CI -3.6 to -6.2; Cohen d=0.77; P<.001), anxiety (95% CI -3.0 to -4.9; Cohen d=0.74; P<.001), overall suicide risk (95% CI -0.5 to -0.1; Cohen d=0.41; P=.02), wish to live (95% CI 0.3 to 1.0; Cohen d=0.39; P<.001), wish to die (95% CI -0.2 to -1.4; Cohen d=0.52; P=.01), and overall mental health (95% CI 1.5 to 4.5; Cohen d=0.39; P<.001) from admission to discharge.

CONCLUSIONS

Rapid adoption and implementation of a group-based teletherapy day program for adults at risk of psychiatric hospitalization appeared to be feasible and effective. Patients demonstrated high completion and attendance rates and reported significant improvements in psychosocial outcomes. Larger trials should be conducted to further evaluate the efficacy and effectiveness of the program through randomized controlled trials.

Clinician Satisfaction with Rapid Adoption and Implementation of Telehealth Services During the COVID-19 Pandemic

Background: To examine clinician perspectives on the acceptability, appropriateness/suitability, and feasibility of video telehealth as a way to deliver mental health services during the COVID-19 pandemic. Materials and Methods: Mental health clinicians were surveyed with 27 Likert questions, using previously validated measures, on satisfaction and implementation experience with video telehealth visits between March and June 2020. Results: A total of 112 of 193 clinicians completed the survey (58.0%), including psychiatrists, psychologists, trainees (i.e., residents and fellows), advanced practice providers, and licensed mental health counselors. Clinicians reported high levels of acceptability, feasibility, and appropriateness of video telehealth; they also reported high levels of satisfaction with video telehealth visits. Seventy-nine and a half (79.5%) reported that their patients seemed highly satisfied with video telehealth visits, and 107 (95.5%) of clinicians responded that they would like video telehealth visits to represent at least 25% of their practice in the future. Discussion: Mental health clinicians showed positive attitudes toward the implementation of video telehealth visits, high levels of satisfaction with this care, and indicated strong interest in continuing this modality as a significant portion of clinical practice. Conclusion: This study demonstrates the ability of mental health clinicians to embrace new technology to expand access to care during the COVID-19 pandemic. Results indicate that telemental health is likely to be an integral part of clinic practice in the future.

Behavioral Activation as a Mechanism of Change in Residential Treatment for Mood Problems: A Growth Curve Model Analysis

Research on the efficacy, effectiveness, and dissemination potential of behavioral activation (BA)-focused interventions for depression and comorbid disorders has expanded rapidly. However, research that examines how BA interventions work has seen less growth. A primary purported mechanism of BA is activation, which reflects a person's meaningful (re)engagement in life. BA theory posits that depression will decrease as activation increases, and that changes in the mechanism variable will lead to changes in outcome. The current study aims to investigate activation as a potential mechanism of change in the context of a BA-focused residential treatment intervention for mood problems using repeated measures of self-reported activation and depression from a large comorbid sample (N = 578). Growth curve modeling was used to examine between-person differences in within-person change over time. Findings suggest that self-reported activation increases and depression decreases over time. Moreover, results show both linear and quadratic growth and that the rate of change in activation predicts the rate of change of depression. BA-focused residential treatment may facilitate activation, which exerts an effect on depression among residents with diagnostically complex presentations.

Feasibility Study of Three-Phase Implementation of International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in an Outpatient Consultation-Liaison Psychiatry Practice

OBJECTIVE

We describe a three-phase implementation of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set in a Consultation-Liaison Psychiatry practice.

METHODS

During the preintervention phase, we reviewed patient-reported outcome tools and engaged stakeholders and leadership. During phase 1, the standard set was converted into an electronic previsit intake assessment that was implemented in a physician champion's practice. Patients completed the intake on a tablet, and computer adaptive testing was used to reduce response burden. Physician-facing data display facilitated use during subsequent in-person visits. An electronic version of the follow-up standard set was used during follow-up visits. During phase 2, a second physician tested scalability and the intervention was disseminated department wide in phase 3.

RESULTS

During phase 1, 186 intakes and 67 follow-up electronic patient-reported outcome sets were completed. Average patient age was 54 years, and 44% were male. On average, patients ranked the tool 4.4 out of 5 and spent 22 minutes completing the intake. Time-driven activity-based costing found the new process to be cost-effective. During phase 2, 386 patients completed electronic patient-reported outcome sets, with 315 follow-up visits. Patients ranked the tool as 4.0 out of 5 and spent 26 minutes completing the questions. During phase 3, 2166 patients completed intake electronic patient-reported outcome sets and 1249 follow-up visits. Patients ranked the tool 4.3 out of 5 and spent 26 minutes on it. Scores and completion time did not differ greatly between phases.

CONCLUSIONS

Integration of the International Consortium for Health Outcomes Measurement Depression and Anxiety Standard Set is feasible. Future research comparing International Consortium for Health Outcomes Measurement set with other approaches and in different settings is needed.

A randomized controlled trial of an online, modular, active learning training program for behavioral activation for depression

OBJECTIVE

This randomized-controlled trial assessed the efficacy of a trainer-led, active-learning, modular, online behavioral activation (BA) training program compared with a self-paced online BA training with the same modular content.

METHOD

Seventy-seven graduate students (M = 30.3 years, SD = 6.09; 76.6% female) in mental health training programs were randomly assigned to receive either the trainer-led or self-paced BA training. Both trainings consisted of 4 weekly sessions covering 4 core BA strategies. Primary outcomes were changes in BA skills as measured by an objective role-play assessment and self-reported use of BA strategies. Assessments were conducted at pre-, post-, and 6-weeks after training. A series of longitudinal mixed effect models assessed changes in BA skills and a longitudinal model implemented with generalized estimating equations assessed BA use over time.

RESULTS

Significantly greater increases in total BA skills were found in the trainer-led training condition. The trainer-led training condition also showed greater increases in all core BA skills either at posttraining, follow-up, or both. Reported use of BA strategies with actual clients increased significantly from pre- to posttraining and maintained at follow-up in both training conditions.

CONCLUSIONS

This trial adds to the literature on the efficacy of online training as a method to disseminate BA. Online training with an active learning, modular approach may be a promising and accessible implementation strategy. Additional strategies may need to be paired with the online BA training to assure the long-term implementation and sustainability of BA in clinical practice. (PsycINFO Database Record

Preferences for Exercise as a Treatment for Depression

Depression is a leading cause of disability worldwide, but most depressed individuals do not receive treatment. There is now significant support for physical exercise as an effective alternative treatment for depression, which may be more accessible than traditional psychiatric treatments. Little is known about preferences for exercise as a depression treatment.

METHOD

A total of 102 individuals (50% female, mean age = 39 (SD=13.1; range: 18-62), 83% Caucasian) with likely major depression completed an online survey of exercise for depression treatment preferences and barriers to increased exercise. Results are reported by gender due to well established gender differences in exercise preferences.

RESULTS

Both genders reported a high level of interest in an exercise for depression program. On average, participants preferred an individual walking program that was coached, asked them to engage in one longer bout multiple times per week, and was provided in home. However, there was significant variability within and between genders. Lack of motivation, mood, and fatigue were reported as barriers to exercise by the majority of participants of both genders.

CONCLUSION

The majority of those with depression have interest in an exercise for depression program, but symptoms of depression are seen as significant barriers. Future studies should use these results to design exercise for depression programs. The variability and gender differences in our results suggest that flexible programs may be needed.

Behavioural activation: history, evidence and promise

Behavioural activation holds promise to reduce the global burden of depression as a treatment approach that is effective, easy to teach, scalable and acceptable to providers and patients across settings and cultures. This editorial reviews the history of behavioural activation, what it is, current evidence for its use and future directions.