Enhancing Quality of Care Through Evidence-Based Practice: Training and Supervision Experiences.

OBJECTIVE: Evidence-based practice (EBP) is the preferred approach to treatment in mental health settings because it involves the integration of the best available research, clinical expertise, and patient values to optimize patient outcomes. Training on empirically supported treatments (ESTs) in mental health settings is an important component of EBP, and supervision of therapists' implementation of ESTs is critical for therapists to develop and maintain a strong EBP skill set. This study aimed to evaluate training and supervision histories of therapists in outpatient and inpatient psychiatric care settings as an essential first step in improving patient outcomes. METHODS: Electronic surveys were completed by 69 therapists, most of whom had a master's degree, within a psychiatry and behavioral sciences department at an academic institution. Participating therapists were recruited from several outpatient and inpatient mental health settings serving children, adolescents, and adults. RESULTS: Although most therapists reported completing some form of EST-related coursework, a majority did not receive any supervision related to implementation of ESTs (51% for cognitive-behavioral therapy cases, 76% for dialectical behavior therapy cases, and 52% for other EST cases) during graduate and postgraduate training. CONCLUSIONS: Although research from the past decade has supported the need for improvements in training on ESTs, and especially in supervision, problems related to limited exposure to training and supervision among therapists still exist. These findings have implications for how mental health centers can evaluate staff members' EST training and supervision experiences, training needs, and associated training targets to improve the quality of routine care.

The moderating role of pessimism in the association between retrospective relational peer victimization, interpersonal risk factors, and suicide ideation.

Peer victimization (PV) is a serious concern for youth and is associated with subsequent suicide ideation in young adulthood. The interpersonal theory of suicide may provide a framework for understanding suicide ideation in this population. Specifically, thwarted belongingness (TB) and perceived burdensomeness (PB) have been significantly associated with suicide ideation among young adults with a history of peer victimization. Additionally, the personality trait of pessimism is associated with elevated suicide ideation. Thus, this study tested the association between self-reported frequency of retrospective relational (i.e., verbal and indirect) PV in primary and secondary school, thwarted interpersonal needs (TB and PB), and current suicide ideation, as well as how these relations may vary based on current pessimism. Participants were 330 undergraduate students. Nonparametric bootstrap moderated mediation procedures were used to test hypotheses. Results indicated significant indirect effects of frequency of retrospective relational PV and suicide ideation through PB and TB. Contrary to predictions, results did not indicate significant moderated mediation; however, the association between PB and suicide ideation was stronger at lower pessimism levels. We also provide supplemental analysis with optimism as the moderator. These findings suggest that clinicians may consider targeting TB, PB, as well as pessimism and optimism among those with a history of relational PV when assessing and intervening on current suicide ideation. Implications, limitations, and future directions are further discussed.

Measuring Self-Efficacy in the Context of Pediatric Diabetes Management: Psychometric Properties of the Self-Efficacy for Diabetes Scale.

Objective: The Self-Efficacy for Diabetes Scale (SED) is a widely used measure of diabetes-specific self-efficacy with three subscales: diabetes-specific self-efficacy (SED-D), medical self-efficacy (SED-M), and general self-efficacy (SED-G). The present study examined the factor structure and construct validity of the SED in 116 youth, aged 10-16 years (13.60 ± 1.87), with type 1 diabetes mellitus. Methods: Confirmatory factor analysis (CFA) was used to examine the factor structure of the SED. Correlational and regression analyses examined relations between subscales and select outcomes. Results: CFA of the original three-factor structure provided a poor fit to the data. Factor models using rescaled items were tested. Results provided preliminary evidence for the SED-D as an independent one-factor model, and for a reduced one-factor model. Significant associations were found between the SED subscales, responsibility for diabetes management, and glycated hemoglobin. Conclusions: Results provide limited support for the SED-D as a reliable and valid measure of diabetes-specific self-efficacy.

Mother-Reported and Children's Perceived Social and Academic Competence in Clinic-Referred Youth: Unique Relations to Depression and/or Social Anxiety and the Role of Self-perceptions.

Depression and social anxiety symptoms and disorders are highly comorbid, and are associated with low social acceptance and academic competence. Theoretical models of both depression and social anxiety highlight the saliency of negative self-perceptions. We examined whether children's self-perceptions of social acceptance and mother-reported youth social acceptance are independently and uniquely related to children's depression and social anxiety, both before and after controlling for comorbid symptoms. Similar questions were examined regarding academic competence. The sample was 110 clinic-referred youth aged 8-16 years (65 boys, 45 girls; M age = 11.15, SD = 2.57). In the social acceptance area, both youth self-perceptions and mother-perceptions had independent and unique relations to depression and social anxiety, before and after controlling for comorbid symptoms. In the academic domain, both youth self-perceptions and mother-perceptions had independent and unique relations to depression, before and after controlling for social anxiety; yet only youth self-perceptions were related to social anxiety, before, but not after controlling for depression. For depression, larger effect sizes were observed for children's perceived, versus mother-reported, social acceptance and academic competence. Bootstrapping and Sobel tests found youth self-perceptions of social acceptance mediated the relation between mothers' perceptions and each of youth depression and social anxiety; and perceived academic competence mediated the relation between mothers' perceptions and youth depression, both before and after controlling for social anxiety. We found similarities and differences in findings for depression and social anxiety. Theoretical and treatment implications are highlighted, and future research directions are discussed.

Provider and patient barriers and facilitators to integration of digital mental health applications in routine clinical care.

BACKGROUND: The limited accessibility of mental healthcare providers highlights the need for innovative approaches to provide effective and efficient care. Digital mental health applications (DMHAs) can improve patient access to evidence-based treatments and reduce burden on the healthcare system. Here, we examined the provider and patient barriers and facilitators to integration of DMHAs in a healthcare system. METHODS: Patients (n = 57) and providers (n = 100) were recruited from a large healthcare system over five months. Participants completed a survey assessing attitudes towards DMHAs, and perceived facilitators and barriers to adoption and utilization of DMHAs in mental healthcare. RESULTS: DMHA credibility was a key facilitator for provider adoption, while usability and accessibility were identified as key facilitators for patient utilization. Provider barriers included patient cost/provider reimbursement, limited knowledge, perceived limits to credibility, patient outcome enhancement, and personalization of DMHAs for patient needs. Patients identified privacy concerns as the top barrier for using DMHAs. LIMITATIONS: The self-report survey nature of this study, modest sample size, and majority of sample identifying as White and upper middle class make results subject to biases and limitations. Given the potential of DMHAs to address disparities in access to mental healthcare, more research is needed including populations who are at greatest risk. CONCLUSIONS: Findings provide new insights to inform the development of intervention strategies to improve the integration of DMHAs within healthcare systems. Additional research examining key stakeholders at different levels of care is critical to address barriers, optimize facilitators, and develop roadmaps for best-practice use in healthcare systems.

Efficacy of stand-alone digital mental health applications for anxiety and depression: A meta-analysis of randomized controlled trials.

BACKGROUND: Anxiety and depressive disorders affect 20% of the population, cause functional impairment, and represent a leading cause of disability. Although evidence-based treatments exist, the shortage of trained clinicians and high demand for mental health services have resulted in limited access to evidence-based care. Digital mental health applications (DMHA) present innovative, scalable, and sustainable solutions to address disparities in mental health care. METHODS: The present study used meta-analytic techniques to evaluate the therapeutic effect of DMHAs in randomized controlled trials (RCTs) for individuals experiencing anxiety and/or depressive symptoms. Search terms were selected based on concepts related to digital mental health applications, mental health/wellness, intervention type, trial design, and anxiety and/or depression symptoms/diagnosis outcomes to capture all potentially eligible results. Potential demographic, DMHA, and trial design characteristics were examined as moderators of therapeutic effects. RESULTS: Random effects meta-analyses found that stand-alone DMHAs produced a modest reduction in anxiety (g = 0.31) and depressive (g = 0.35) symptom severity. Several moderators influenced the therapeutic effects of DMHAs for anxiety and/or depressive symptoms including treatment duration, participant inclusion criteria, and outcome measures. LIMITATIONS: Minimal information was available on DMHA usability and participant engagement with DMHAs within RCTs. CONCLUSIONS: While DMHAs have the potential to be scalable and sustainable solutions to improve access and availability of evidence-based mental healthcare, moderator analyses highlight the considerations for implementation of DMHAs in practice. Further research is needed to understand factors that influence therapeutic effects of DMHAs and investigate strategies to optimize its implementation and overcome the extant research-to-practice gap.

Factors Associated With Pediatric Burn Clinic Follow-up After Emergency Department Discharge.

Attrition between emergency department discharge and outpatient follow-up is well documented across a variety of pediatric ailments. Given the importance of outpatient medical care and the lack of related research in pediatric burn populations, we examined sociodemographic factors and burn characteristics associated with outpatient follow-up adherence among pediatric burn patients. A retrospective review of medical records was conducted on patient data extracted from a burn registry database at an urban academic children's hospital over a 2-year period (January 2018-December 2019). All patients were treated in the emergency department and discharged with instructions to follow-up in an outpatient burn clinic within 1 week. A total of 196 patients (Mage = 5.5 years; 54% male) were included in analyses. Average % TBSA was 1.9 (SD = 1.5%). One third of pediatric burn patients (33%) did not attend outpatient follow-up as instructed. Older patients (odds ratio [OR] = 1.00; 95% confidence interval [CI]: [0.99-1.00], P = .045), patients with superficial burns (OR = 9.37; 95% CI: [2.50-35.16], P = .001), patients with smaller % TBSA (OR = 1.37; 95% CI: [1.07-1.76], P = .014), and patients with Medicaid insurance (OR = 0.22; 95% CI: [0.09-0.57], P = .002) or uninsured/unknown insurance (OR = 0.07; 95% CI: [0.02-0.26], P = .000) were less likely to follow up, respectively. Patient gender, race, ethnicity, and distance to clinic were not associated with follow-up. Follow-up attrition in our sample suggests a need for additional research identifying factors associated with adherence to follow-up care. Identifying factors associated with follow-up adherence is an essential step in developing targeted interventions to improve health outcomes in this at-risk population.

Internalizing symptoms and sleep outcomes in urban children with and without asthma.

STUDY OBJECTIVES: This study examines associations between internalizing symptoms and sleep in a sample of urban children with and without asthma, whether asthma status moderates these associations, and whether associations differ by ethnic group. METHODS: Participants were Latino, African American (AA), and non-Latino white (NLW) urban 7- to 9-year-olds with (n = 259) and without (n = 122) persistent asthma. Teacher-reported internalizing symptoms (anxiety, depressive, and somatic) were assessed using the Behavioral Assessment System for Children-2. Sleep duration, variability in sleep duration, and sleep onset latency were assessed with actigraphy. RESULTS: Depressive symptoms were associated with variability in sleep duration and shorter sleep onset latency; somatic symptoms were associated with variability in sleep duration. In Latino children, depressive symptoms were associated with shorter sleep onset latency. In AA children, anxiety, depressive, and somatic symptoms were associated with variability in sleep duration; somatic symptoms were related to variability in sleep duration in NLW children. The association between internalizing symptoms and sleep outcomes did not differ by asthma status. However, asthma status was a significant moderator when examining these associations by ethnic group: among AA children, depressive symptoms were significantly related to variability in sleep duration only in children with asthma, whereas in NLW children, somatic symptoms were related to variability in sleep duration only in children without asthma. CONCLUSIONS: Targeting specific internalizing symptoms and sleep outcomes may be beneficial in the development of interventions tailored for urban children with and without asthma from specific ethnic groups.

Retrospective Cyberbullying and Suicide Ideation: The Mediating Roles of Depressive Symptoms, Perceived Burdensomeness, and Thwarted Belongingness.

Research suggests that being cyberbullied is associated with increased risk for suicide ideation; however, few studies have examined the underlying mechanisms of this relation, and fewer have examined this relation within a theory of suicide. Specifically, the interpersonal theory of suicide posits that thwarted belongingness (indicated by loneliness and a lack of reciprocal caring relationships) and perceived burdensomeness (indicated by feelings of liability and self-hatred) increase risk for suicide ideation. The current study aimed to examine depressive symptoms, thwarted belongingness, and perceived burdensomeness as mediators between intensity of being cyberbullied and suicide ideation. Participants were college students ( N = 348) who completed assessments of retrospective peer victimization, thwarted interpersonal needs (i.e., thwarted belongingness and perceived burdensomeness), and suicide ideation. The results indicated that after adjusting for sexual orientation, depressive symptoms significantly mediated the relation between intensity of being cyberbullied and suicide ideation. Furthermore, depressive symptoms and perceived burdensomeness serially mediated the relation between intensity of being cyberbullied and suicide ideation; however, thwarted belongingness was not a significant mediator. Clinical and research implications, limitations, and future directions are discussed.

Moderating role of trait hope in the relation between painful and provocative events and acquired capability for suicide.

BACKGROUND: The interpersonal theory of suicide has gained empirical support as a conceptualization of suicide risk; however, little research has examined the role of individual traits, such as trait hope, within the interpersonal theory of suicide. AIMS: The purpose of this study was to further investigate the role of trait hope components (i.e., pathways and agency) in acquired capability for suicide. METHOD: Participants were 711 college students who completed measures of acquired capability for suicide, painful and provocative events, and trait hope (i.e., pathways and agency). Linear regression was used to test the hypotheses. RESULTS: As hypothesized, there was a positive relation between pathways and acquired capability. Contrary to our hypotheses, after controlling for gender there was a significant relation between agency and acquired capability. In addition, after controlling for gender, pathways did not moderate the relation between painful and provocative events and acquired capability, whereas agency did moderate this relation. CONCLUSION: Painful and provocative events should be assessed as a risk factor for acquired capability for suicide, and this may be more salient for individuals higher in the agency component of trait hope. Future research should consider examining the role of other traits within the interpersonal theory of suicide.