Abstract: Turnover in community mental health clinics threaten the delivery of quality behavioral health services; recovery orientation has been shown to be associated with lower levels of burnout but its relationship with actual turnover has not yet been examined. This study aimed to examine the relationship between provider perceptions of recovery orientation and 12-month turnover status among community mental health providers. Secondary data analyses were conducted with data collected from 224 community mental health providers from ten organizations across 14 clinic sites participating in a larger effectiveness-implementation trial. Chi square analyses were used to examine between-site variation in 1-year turnover rates among the ten organizations. Logistic regression was used to examine effects of perceptions of recovery orientation along with known predictors of turnover among community mental health providers. Results revealed no between-site variation in organizational turnover rates. The logistic regression model was statistically significant, χ2(17) = 47.64, p < .0001 and explaining 30% (Nagelkerke R2) of within-site variance and correctly classifying 79% of cases. Perceptions of recovery orientation emerged as the sole significant predictor of 12-month turnover status, with higher levels of recovery orientation significantly associated with lower odds of turnover at 12 months [B = .90, p = .008, OR 2.47 (95% CI 1.23, 4.82)]. Perceptions of recovery orientation was protective against 12-month turnover status suggesting that a more person-centered and empowering approach to care may improve the provider experience. More research is needed to further understand how recovery orientation can contribute to workforce stability. PubDate: 2021-05-06
Abstract: Measurement based care (MBC) improves client outcomes by providing clinicians with routine mental health outcome data that can be used to inform treatment planning but is rarely used in practice. The Monitoring and Feedback Attitudes Scale (MFA) and Attitudes Towards Standardized Assessment Scales-Monitoring and Feedback (ASA-MF) (Jensen-Doss et al., 2016) may identify attitudinal barriers to MBC, which could help trainings and implementation strategies. This study examines the psychometric properties of the MFA and ASA-MF, including the factor structure, longitudinal invariance, and indicators of validity, in a sample of community mental health clinicians (N = 164). The measures demonstrate adequate fit to their factor structures across time and predict MBC use as captured in a client’s electronic health record. Given that clinician attitudes are associated with MBC use, using instruments with psychometric support to assess attitudes fills a research to practice gap. PubDate: 2021-05-03
Abstract: Evidence-based supported employment has become a core community mental health service in much of the U.S. Although a national learning community has facilitated progress in about half of the states, other states have tried to implement evidence-based supported employment on their own. Many studies have examined site-level factors influencing implementation of supported employment, but few have focused on the role of state agency policies and actions. This study examined four states that have not joined the learning community, comparing two that have implemented with success (adopting states) and two that have faced challenges (non-adopting states). This comparative case study approach compared barriers, facilitators, and strategies in two states adopting IPS to two states that did not. The authors examined quantitative data from public records and conducted content analysis of qualitative and quantitative data from key informant interviews. The two non-adopting states lacked model clarity, funding, focus on people with serious mental illness, and collaboration between state mental health and vocational rehabilitation agencies. The two successful states experienced similar barriers but overcame them following lawsuit settlements that required implementation of evidence-based supported employment. Key strategies for successful implementation were funding, fidelity monitoring, technical assistance, and collaboration between state mental health and vocational rehabilitation agencies. With legal settlements serving as the catalyst, states facing challenges to implementing evidence-based supported employment can achieve success using standard implementation strategies to fund and ensure the quality of services. PubDate: 2021-05-01
Abstract: The COVID-19 pandemic exacerbates the mental, emotional, and behavioral (MEB) health problems of children and adolescents in the United States (U.S.). A collective and coordinated national economic and social reconstruction effort aimed at shoring up services to promote children's MEB, like the Marshall Plan that helped rebuild Europe post-World War II, has been proposed to buttress against the expected retrenchment. The plan prioritizes children's well-being as a social objective. We propose strategically reconstructing the public safety-net systems serving youth, including early education, maternal and child health, child welfare, corrections, and mental health. That plan called for a concentrated focus on coalition-building and contracting by state mental health systems to establish a foundation for an improved health system. This paper offers a complementary set of suggestions for the four non-mental health systems mentioned above by recommending actionable steps based on scientific evidence to support improved services for children at risk for MEB problems. For each system we describe examples of evidence-informed services, policies or programs that (1) prevent disabilities and promote health, (2) protect and preserve families and neighborhoods, and (3) provide quality care. Prioritizing the promotion of children's MEB health by all state systems can shape U.S. children's health and well-being for generations to come. PubDate: 2021-05-01
Abstract: School mental health treatment services offer broad public health impact and could benefit from more widespread implementation and sustainment of standardized assessments (SA). This demonstration study describes one approach to increase SA use in a large school behavioral health network using the Exploration, Preparation, Implementation and Sustainment (EPIS) framework. Mental health administrator interviews with four participating agencies and a multidisciplinary planning team informed SA measure selection and implementation supports. The SA initiative was implemented during one school year, including system-wide training and ongoing implementation supports for 95 clinicians. Linear mixed effect models revealed improvements in clinician attitudes about the SA for clinical utility and treatment planning immediately following the half-day training (N = 95, p < .001). Clinicians self-reported a significant increase in use of SA for new clients during intakes (p < .001) over time and 71.4% of expected SA data were submitted. Qualitative feedback, including recommendations to offer more SA choices and beginning new SA data collection earlier in the school year, was integrated to inform quality improvements and future sustainment efforts. PubDate: 2021-05-01
Abstract: The suicide rate of farmers is approximately double that of the general Australian population, yet farmers employ fewer help-seeking behaviours (Arnautovska et al. in Soc Psychiatry Psychiatr Epidemiol 49:593–599, 2014; Brew et al. in BMC Public Health 16:1–11, 2016). Therefore, it is crucial to understand if, and how health services and system might influence farmer help-seeking. To shed light on this, the current study employed qualitative semi-structured interviews with 10 farmers, 10 farmers’ partners and 8 medical practitioners. Thematic analysis, guided by Braun and Clarke’s (Qual Res Psychol 3:77–101, 2006) techniques, was used to analyse the data. Three themes were devised concerning the interaction between farmers and health services, including ‘health service interactions’, ‘services are provided within a complex system’ and ‘emerging technologies: the users, practitioners, and systems’. The findings underscore the importance of interactions between a farmer and a service provider, with farmers wanting their provider to have an understanding of farming life. Help-seeking was also shaped by access, availability, and practitioner constancy. Lastly, a complex relationship between digital mental health services and farmer help-seeking was reported, with factors related to the farmers, the practitioners and the infrastructure/systems discussed. The outcomes have implications for health service and policy reform, developing and providing interventions for farmers to promote health services interaction as a way of mental health help-seeking. PubDate: 2021-05-01
Abstract: The COVID-19 pandemic has caused massive unemployment, exacerbated pre-existing behavioral health (mental health and substance use) disorders for many people, and created new disorders for others. Although policy changes have increased health care and unemployment benefits, most people want jobs and self-sufficiency rather than handouts. A robust evidence base shows that supported employment can enable unemployed people with behavioral health conditions to find competitive, integrated employment and behavioral health supports. Millions of U.S. citizens may need these services as the pandemic recedes and jobs become available. Government attention to supported employment is necessary now more than ever. PubDate: 2021-05-01
Abstract: A meta-analysis was conducted to examine the relative rates of youth mental health service utilization across settings among the general population and among those with elevated mental health symptoms or clinical diagnoses. Rates of school-based mental health were compared to outpatient, primary care, child welfare, juvenile justice, and inpatient. Nine studies presented rates of mental health service use for general-population youth in the U.S., and 14 studies presented rates for youth with elevated symptoms or clinical diagnoses. Random effects meta-analysis was used to calculate mean proportions of youth receiving care in each sector. Of general population youth, 7.28% received school mental health services. Rates for other sectors are as follows: 7.26% in outpatient settings, 1.76% in primary care, 1.80% in inpatient, 1.35% in child welfare, and 0.90% juvenile justice. For youth with elevated mental health symptoms or diagnoses, 22.10% of youth were served by school-based mental health services, 20.56% outpatient settings, 9.93% primary care, 9.05% inpatient, 7.90% child welfare, and 4.50% juvenile justice. Schools and outpatient settings are the most common loci of mental health care for both the general population and samples of youth with elevated symptoms or clinical diagnoses, although substantial amounts of care are also provided in a range of other settings. Results hold potential for informing resource allocation, legislation and policy, intervention development, and research. Given that mental health services are delivered across many settings, findings also point to the need for interconnection across child-serving sectors, particularly schools and outpatient clinics. PubDate: 2021-05-01
Abstract: Although physical and behavioral health conditions commonly cooccur, best practices making behavioral health treatment responsive to clients’ health needs are limited. Particularly little is known about how physical health is addressed by clinicians within routine therapeutic treatment. This study describes the frequency and type of health talk occurring within integrated behavioral health sessions, and explores how this talk functions within ongoing therapeutic work. Participants in this study included 51 dyads of clinical social workers (n = 13) and clients (n = 51) receiving therapy within an integrated community health and behavioral health center. Therapy sessions were recorded and transcribed verbatim. Content analysis determined the frequency and content of health talk in sessions. Thematic analysis was used to understand the function of health talk within these visits. Health talk occurred in 92% (n = 47) of sessions. Clients initiated the majority of discussions. Talk about sleep (40%, n = 19), diet/exercise (35%, n = 16), and chronic health conditions (28%, n = 13) were most common. Health talk either complimented or conflicted with therapeutic work, depending on the topic discussed and when it occurred during session. Health talk changed the scope of therapeutic work by integrating care coordination into routine practice. Health talk was pervasive and was frequently initiated by clients, signaling its relevance to clients’ recovery. Providers leveraged heath talk to complement their therapeutic work, but these strategies were not universally applied. Care coordination activities were a part of routine therapy. Practice and policy changes that support a more interdisciplinary approach to clinical work are needed. PubDate: 2021-05-01
Abstract: This study examined the cost-effectiveness of standard parent–child interaction therapy (PCIT) and three adaptations: intensive-PCIT (I-PCIT), small group PCIT, and large group PCIT. This study used cost-effectiveness analyses to calculate average cost-effectiveness ratios, which represents the average cost for one family to change one standard deviation on each outcome measure: externalizing behavior problems, positive parenting skills, negative parenting skills, child compliance, and parenting stress. While it had the lowest initial set up cost, results indicated that standard PCIT was the least cost-effective option in reducing child disruptive behaviors and in increasing child compliance. Large group PCIT was the most cost-effective in increasing positive parenting skills and child compliance and in reducing negative parenting skills and parenting stress. I-PCIT was the most cost-effective in reducing child disruptive behaviors and the second most cost-effective option in increasing positive parenting skills and child compliance and in decreasing negative parenting. As large group and I-PCIT were the most cost-effective in different domains, both could be recommended to parents as treatment options. Future research should confirm our cost-effective results within community settings. PubDate: 2021-05-01
Abstract: While mental health system reforms have sought to leverage competition in the private sector to improve service quality and costs, competition among mental health organizations is poorly understood. To inform future studies about the impact of policy and system reforms on mental health organizations and service delivery, this qualitative study explores (1) resources for which organizations compete most intensively, (2) drivers of competition, and (3) leaders’ strategic organizational responses. Semi-structured phone interviews were conducted with 15 organizational leaders (CEO’s, executive directors) representing about 22% of organizations in the regional mental health market. Interviews covered leaders’ perceptions about competition, and their strategic responses. Porter’s seminal framework on competition was used to interpret codes and themes. Intensive competition for personnel was driven by workforce shortages, new for-profit organizations, and alternative employment opportunities. In response, organizations have attended to wages/benefits, recruitment, and retention. However, strong community need, expanded insurance coverage, and a history of local strategic responses that created service niches appeared to have minimized competition for financial resources in the region. Competition for funding and clients was expected to intensify under systems reform, and in anticipation, organizations were expanding services. Leaders also feared for the viability of smaller organizations in highly competitive environments. Consistent with theory on competition, mental health organizations compete and respond in ways that might improve services. However, the goals of privatization may have been unrealized because of minimal competition for funding and clients, and intense competition may undermine quality. PubDate: 2021-05-01
Abstract: To evaluate an implementation intervention to increase the uptake, referred to as reach, of two evidence-based psychotherapies (EBP) for posttraumatic stress disorder (PTSD) in Veterans Health Administration (VHA) PTSD specialty clinics. The implementation intervention was external facilitation guided by a toolkit that bundled strategies associated with high EBP reach in prior research. We used a prospective quasi-experimental design. The facilitator worked with local champions at two low-reach PTSD clinics. Each intervention PTSD clinic was matched to three control clinics. We compared the change in EBP reach from 6-months pre- to post-intervention using Difference-in-Difference (DID) effect estimation. To incorporate possible clustering effects and adjust for imbalanced covariates, we used mixed effects logistic regression to model the probability of EBP receipt. Analyses were conducted separately for PTSD and other mental health clinics. 29,446 veterans diagnosed with PTSD received psychotherapy in the two intervention and six control sites in the two 6-month evaluation periods. The proportion of therapy patients with PTSD receiving an EBP increased by 16.98 percentage points in the intervention PTSD clinics compared with .45 percentage points in the control PTSD clinics (DID = 16.53%; SE = 2.26%). The adjusted odd ratio of a patient receiving an EBP from pre to post intervention was almost three times larger in the intervention than in the control PTSD clinics (RoR 2.90; 95% CI 2.22–3.80). EBP reach was largely unchanged in other (not PTSD specialty) mental health clinics within the same medical centers. Toolkit-guided external facilitation is a promising intervention to improve uptake of EBPs in VHA. Toolkits that pre-specify targets for clinic change based on prior research may enhance the efficiency and effectiveness of external facilitation. Trial registration ISRCTN registry identifier: ISRCTN65119065. Available at https://www.isrctn.com/search'q=ISRCTN65119065. PubDate: 2021-05-01
Abstract: Individuals with serious mental illness (SMI) face significant health disparities and multiple barriers to engaging in health behavior change. To reduce these health disparities, it is necessary to enhance the support individuals with SMI receive through the collaboration of different healthcare providers. This study explored how people with SMI living in supportive housing perceived receiving support from peer and non-peer providers for their physical health. Qualitative interviews were conducted with 28 participants receiving a peer-led healthy lifestyle intervention in the context of a randomized trial in supportive housing agencies. Interviews explored participants’ experiences working with the healthy lifestyle peer specialist and a non-peer provider who assisted them with health. Interviews were audio recorded, transcribed, and analyzed using strategies rooted in grounded theory. Participants viewed their relationships with peer and non-peer providers positively, but described differences in the approach to practice, power dynamics present, and how they identified with each provider. Participants described peers as process-oriented while non-peer staff as task-oriented, focusing on accomplishing concrete objectives. Each provider sought to boost participants’ motivation, but peers built hope by emphasizing the possibility of change, while non-peer providers emphasized the consequences of inaction. Participants related to peer staff through shared experiences, while identifying the importance of having a shared treatment goal with their non-peer provider. Overall, participants appreciated the unique roles of both peer and non-peer staff in supporting their health. Study findings have implications for integrating the use of peer-based health interventions to improve the health of people with SMI. PubDate: 2021-05-01
Abstract: This paper presents the results of a qualitative study designed to explore and identify the resources that probation officers need to implement specialized mental health probation caseloads, a promising practice that enhances mental health treatment engagement and reduces recidivism among people with mental illnesses. Our research team conducted a directed content analysis guided by the Practical, Robust Implementation and Sustainability Model (PRISM) to analyze qualitative interviews with 16 specialty mental health probation officers and their supervising chiefs. Results indicated five components and resources related to multiple PRISM constructs: (1) meaningfully reduced caseload sizes (intervention design), (2) officers’ ability to build rapport and individualize probation (organizational staff characteristics), (3) specialized training that is offered regularly (implementation and sustainability infrastructure), (4) regular case staffing and consultation (implementation and sustainability infrastructure), and (5) communication and collaboration with community-based providers (external environment). Agencies implementing specialized mental health probation approaches should pay particular attention to selecting officers and chiefs and establishing the infrastructure to implement and sustain specialty mental health probation. PubDate: 2021-05-01
Abstract: Crisis hotlines are a fixture in providing mental health services to individuals experiencing mental and behavioral problems in the United States (U.S.). Despite this, and the growing need for easily-accessible, anonymous, and free services amidst the suicide and opioid crises, there is no study reporting U.S. national prevalence and correlates of hotline use. Data on n = 18,909 participants from the Collaborative Psychiatric Epidemiology Surveys (CPES), a group of three nationally-representative, population-based studies, were used to estimate the prevalence of lifetime and past 12-month hotline use. A series of logistic regression models examined sociodemographic, clinical history and service use correlates of hotline use. Lifetime and past 12-month hotline use was estimated at 2.5% and 0.5%, respectively. Being female, having a mental or behavioral disorder, experiencing suicidality, or interacting with other formal and informal sectors of the mental health service system were significant correlates of use. This study provides the first national estimates of crisis hotline usage in the U.S. Hotlines are more likely to be used by certain sociodemographic subgroups, but these differences may be due to differing psychiatric history and service use patterns. Efforts should be made to ensure that crisis hotlines are being utilized by other marginalized populations at high risk of suicide or overdose amidst the current public health crises in the U.S., such as racial/ethnic minorities or youth. To evaluate the role that crisis hotlines play in the mental health service system, national surveys should aim to monitor trends and correlates over time. PubDate: 2021-05-01
Abstract: Through everyday interactions, mental health clinicians are exposed to their colleagues’ views toward new treatments, which can influence clinicians’ own attitudes and implementation especially in high-stress environments. This study examines how exposure to peers’ attitudes in the workplace through three common workplace interactions (advice sharing, discussion, and friendship) shapes clinicians’ (n = 163) own attitudes toward measurement-based care (MBC). Clinicians tended to have more positive attitudes toward MBC with greater exposure to peers with positive attitudes through advice-sharing and informal workplace discussions, but not through friendships. Results highlight the importance of strong workplace relationships for implementation. PubDate: 2021-05-01
Abstract: Autism spectrum disorder (ASD) is a highly prevalent neurodevelopmental disorder. ASD community-based organizations (ASD-CBOs) underutilize or inconsistently utilize evidence-based practices (ASD-EBPs) despite numerous available EBPs to treat ASD. Nonetheless, ASD-CBOs implement changes to practices regularly. Understanding ASD-CBO’s implementation-as-usual (IAU) processes may assist to develop strategies to facilitate ASD-EBP adoption, implementation and sustainment. A convergent mixed methods (quan + QUAL) design was utilized. Twenty ASD-CBO agency leaders (ALs) and 26 direct providers (DPs), from 21 ASD-CBOs, completed the Autism Model of Implementation Survey Battery, including demographic and agency IAU process questions. Surveys were analyzed through descriptive and content analyses. A subset of 10 ALs provided qualitative interview data that were analyzed using coding, consensus and comparison methods to allow for a more comprehensive understanding of the IAU process within their ASD-CBOs. Quantitative analyses and qualitative coding were merged utilizing a joint display and compared. Results suggest that the IAU process follows some phases identified in the Exploration, Preparation, Implementation, Sustainment (EPIS) framework but were conducted in an informal manner—lacking specificity, structure and consistency across and within ASD-CBOs. Moreover, data suggest adding a specific adoption decision phase to the framework. Nonetheless, most ALs felt previous implementation efforts were successful. IAU processes were explored to determine whether the implementation process may be an area for intervention to increase ASD-EBP utilization in ASD-CBOs. Developing a systematized implementation process may facilitate broader utilization of high quality ASD-EBPs within usual care settings, and ultimately improve the quality of life for individuals with ASD and their families. PubDate: 2021-05-01
Abstract: Pragmatic instruments with psychometric support are important to advance dissemination and implementation (D&I) research, but few well-researched D&I instruments exist. Item response theory (IRT), an approach that is underutilized in D&I, can help with the development of actionable and brief instruments. This paper provides an overview of IRT for D&I researchers and examines an instrument of therapist attitudes using IRT measurement models. Eight items of the Attitudes Towards Individualized Assessment—Monitoring and Feedback (AIA-MF) Clinical Utility scale were fit to the Graded Response Model in a national sample of master’s level therapists. Various IRT model characteristics including item threshold and discrimination parameters, information, and item and person fit were examined. Discrimination and thresholds parameters showed significant variability across the eight items. Item information curves also showed that each item contributed variably to the total test information, suggesting that items 4 and 5 reliably measure therapist attitudes across the latent continuum and items 3 and 6 warrant further investigation. Results suggest that IRT models can help D&I researchers examine existing instruments with greater specificity than traditional measurement methods, thus increasing measurement precision while lowering response burden, both important considerations for the field. PubDate: 2021-04-30
Abstract: Youth with autism spectrum disorder (ASD) have high rates of co-occurring mental health needs that necessitate mental health interventions. Given the unique clinical characteristics of youth with ASD, there have been significant efforts to adapt and test mental health interventions for this population. Yet, characterization of the nature and types of interventions adaptations is limited, especially across the wide range of interventions tested for youth with ASD with a focus on implementation factors. Additionally, understanding how these interventions may be implemented in community services is limited. The aims of this systematic review are to characterize the (1) types of interventions tested for co-occurring mental health conditions for youth with ASD; (2) adaptations to mental health interventions for use with youth with ASD; and (3) implementation strategies, outcomes, and determinants of mental health interventions to inform their translation to community service settings. Eighty-three articles testing interventions targeting mental health symptoms in youth with ASD that included implementation factors in analyses were reviewed. The Stirman et al. (2013; 2019) FRAME adaptation, Powell et al. (2012;2015) implementation strategies, and Proctor et al. (2011) implementation outcomes taxonomies were applied to characterize the nature and types of adaptations for use with youth with ASD and types of implementation strategies, outcomes, and determinants used, when available, respectively. Of the interventions examined, the majority (64.1%) were originally designed to target youth mental health concerns and were then adapted to be used with ASD. The most common adaptations included those to the intervention content, particularly adding elements with tailoring or refining aspects of the intervention while maintaining core functions. Half of the articles described at least one implementation strategy used during intervention testing. Fidelity and acceptability were the most frequently examined implementation outcomes, with some examination of appropriateness and feasibility. Nineteen percent of articles described implementation determinants (i.e. barriers/facilitators) of these implementation outcomes. The common adaptations for ASD provide direction for future intervention development and for training community therapists. Further examination, specification, and reporting of implementation strategies and outcomes within ongoing efforts to adapt and interventions to meet the co-occurring mental health needs of youth ASD are needed to facilitate their translation to community settings. Areas for future research as well as clinical implications are discussed. PubDate: 2021-04-21
Abstract: Supported by the 10% set-aside funds in the Community Mental Health Block grant, distributed at the state level, coordinated specialty care (CSC) have been widely disseminated throughout the U.S. This study explores variations in the geographical accessibility of CSC programs by neighborhood level characteristics in Washington State. CSC locations were geocoded. Socioeconomic neighborhood deprivation (i.e., Area deprivation index) and rurality (i.e., Rural–Urban Commuting Area codes) were neighborhood level characteristics extracted from the 2018 American Community Survey. Geographic accessibility of CSC was assessed using a two-step floating catchment area technique and multilevel linear models were used to examine the association between specific neighborhood characteristics and geographic accessibility. The association between access and socioeconomically deprived neighborhoods varied differentially by neighborhood rurality (an interaction effect). Model estimates indicated that the least deprived, metropolitan neighborhoods had the best access (M = 0.38; CI: 0.34, 0.42) and rural neighborhoods in the second most deprived quartile had the worst access (M = 0.16; CI: 0.11, 0.21) to CSC. There was a clear decrease in accessibility for more rural neighborhoods, regardless of other neighborhood characteristics. In conclusions, findings provide important insight into how resource distribution contributes to geographic disparities in access to CSC. The use of spatial analytic techniques has the potential to identify specific neighborhoods and populations where there is a need to expand and increase availability of CSC to ensure access to rural and socioeconomically deprived neighborhoods. PubDate: 2021-04-20
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