Private Practice, Private Insurance, and Private Pay Mental Health Services: An Understudied Area in Implementation Science.

The private practice setting is understudied. Private practice includes settings in which mental health providers are unaffiliated with healthcare and hospital systems. Private practices may accept insurance (private and sometimes public) or no insurance (private pay). Increasing attention to this setting is critical to facilitating equitable access to mental health services, especially given enduring mental health workforce shortages and service waitlists. Further, there have been recent federal government calls to increase mental health and physical healthcare parity and to reduce out-of-pocket patient costs. Implementation science theories, models, frameworks, and methods can help illuminate determinants of private practice service availability and quality (e.g., evidence-based intervention delivery with fidelity), guide evaluation of implementation outcomes such as cost and acceptability of interventions to patients, and identify strategies to mitigate barriers to high-quality, affordable private practice services. This article suggests research questions to begin filling the private practice research gap using an implementation determinants framework - the Consolidated Framework for Implementation Research (CFIR) 2.0. Research questions are proposed across CFIR domains: outer context (e.g., policies impacting whether private practices accept insurance); individuals involved (e.g., provider professional experiences; direct-to-consumer marketing impacts on evidence-based intervention demand); innovation characteristics (e.g., appropriateness for private practice); inner context (e.g., organizational characteristics); and implementation processes (e.g., innovation sustainability). The illustrative research questions aim to begin a conversation amongst researchers and funders. Bringing an implementation science lens to the private practice context has the potential to improve the quality and affordability of mental health care for many.

From court to the community: improving access to evidence-based treatment for underserved youth involved in the juvenile legal system at-risk for suicide.

BACKGROUND: Juvenile legal involved youth (JLIY) experience disproportionately high rates of suicidal and self-injurious thoughts and behaviors (SSITB). Many JLIY lack access to evidence-based treatment specifically designed to treat SSITB, thereby increasing the overall risk of suicide. The overwhelming majority of JLIY are not placed in secure facilities and almost all incarcerated youth are eventually released to the community. Consequently, SSITB are a major concern of JLIY residing in the community and it is critical that this population has access to evidence-based treatment for SSITB. Unfortunately, most community mental health providers who treat JLIY have not been trained in evidence-based interventions that are specifically designed to SSITB, which often leads to youth experiencing prolonged periods of SSITB. Training community mental health providers who serve JLIY in the detection and treatment of SSITB shows promise for decreasing the overall suicide risk for JLIY. METHODS: The current proposal aims to reduce SSITB among JLIY, and thus reduce mental health disparities in this vulnerable and underserved youth population, by increasing access to evidence-based treatment strategies specifically designed to treat SSITB behaviors. We will implement an agency-wide training among at least 9 distinct community mental health agencies that serve JLIY referred to treatment by a statewide court system in the Northeast. Agencies will be trained in an adapted version of the COping, Problem Solving, Enhancing life, Safety, and Parenting (COPES+) intervention. Training will be implemented via a cluster-randomized stepped wedge trial that proceeds through multiple phases. DISCUSSION: This research engages multiple systems (i.e., juvenile legal and mental health systems) serving JLIY and has the potential to directly inform treatment practices in juvenile legal and mental health systems. The current protocol has significant public health implications as the primary goals are to reduce SSITB among adolescents involved in the juvenile legal system. By implementing a training protocol with community-based providers to help them learn an evidence-based intervention, this proposal aims to reduce mental health disparities in a marginalized and underserved population. TRIAL REGISTRATION: osf.io/sq9zt.

Therapist perceptions of experiential training for exposure therapy.

BACKGROUND: Despite evidence for its efficacy, exposure therapy for anxiety is rarely used in routine care settings. Efforts to address one major barrier to its use - therapists' negative beliefs about exposure - have included therapist-level implementation strategies, such as training and consultation. Experiential training, in which therapists themselves undergo exposures, has recently demonstrated feasibility, acceptability and preliminary effectiveness for increasing exposure use. AIMS: This study aimed to assess: (1) therapists' perceptions of experiential training and (2) barriers and facilitators to implementing exposure following training. METHOD: Therapists who underwent experiential training (n=12) completed qualitative interviews and quantitative questionnaires. Interviews were coded using an integrated approach, combining both inductive and deductive approaches. Mixed methods analyses examined how themes varied by practice setting (community mental health versus private practice) and exposure use. RESULTS: Results highlight how therapist-level factors, such as clinician self-efficacy, interact with inner- and outer-setting factors. Participants reported positive perceptions of exposure after training; they noted that directly addressing myths about exposure and experiencing exposures themselves improved their attitudes toward exposure. Consistent with prior literature, issues such as insufficient supervisory support, organizational constraints, and client characteristics made it challenging to implement exposures. DISCUSSION: Results highlight the benefits of experiential training, while also highlighting the need to consider contextual determinants. Differences in responses across practice settings highlight areas for intervention and the importance of tailoring implementation strategies. Barriers that were specific to therapists who did not use exposure (e.g. hesitancy about its appropriateness for most clients) point to directions for future implementation efforts.

The evolution of sour taste.

The evolutionary history of sour taste has been little studied. Through a combination of literature review and trait mapping on the vertebrate phylogenetic tree, we consider the origin of sour taste, potential cases of the loss of sour taste, and those factors that might have favoured changes in the valence of sour taste-from aversive to appealing. We reconstruct sour taste as having evolved in ancient fish. By contrast to other tastes, sour taste does not appear to have been lost in any major vertebrate taxa. For most species, sour taste is aversive. Animals, including humans, that enjoy the sour taste triggered by acidic foods are exceptional. We conclude by considering why sour taste evolved, why it might have persisted as vertebrates made the transition to land and what factors might have favoured the preference for sour-tasting, acidic foods, particularly in hominins, such as humans.

Split down the middle: studying arbuscular mycorrhizal and ectomycorrhizal symbioses using split-root assays.

Most land plants symbiotically interact with soil-borne fungi to ensure nutrient acquisition and tolerance to various environmental stressors. Among these symbioses, arbuscular mycorrhizal and ectomycorrhizal associations can be found in a large proportion of plants, including many crops. Split-root assays are widely used in plant research to study local and systemic signaling responses triggered by local treatments, including nutrient availability, interaction with soil microbes, or abiotic stresses. However, split-root approaches have only been occasionally used to tackle these questions with regard to mycorrhizal symbioses. This review compiles and discusses split-root assays developed to study arbuscular mycorrhizal and ectomycorrhizal symbioses, with a particular emphasis on colonization by multiple beneficial symbionts, systemic resistance induced by mycorrhizal fungi, water and nutrient transport from fungi to colonized plants, and host photosynthate allocation from the host to fungal symbionts. In addition, we highlight how the use of split-root assays could result in a better understanding of mycorrhizal symbioses, particularly for a broader range of essential nutrients, and for multipartite interactions.

Accommodation of Anxiety in Youth with Autism Spectrum Disorder: Results from the TAASD Study.

Objective: Accommodation, or the ways in which families modify their routines and expectations in response to a child's anxiety, is common and interferes with anxiety treatment outcomes. However, little research has examined family accommodation among youth with autism spectrum disorder and anxiety. The current study aimed to (a) identify pre-treatment correlates of accommodation, (b) examine changes in accommodation after treatment, and (c) assess relationships between accommodation and post-treatment anxiety severity.Method: The sample consisted of 167 youth (mean age = 9.90 years; 79.6% male; 18% Latinx) with clinically significant anxiety and a diagnosis of autism spectrum disorder who were enrolled in a randomized clinical trial comparing two cognitive behavioral therapy interventions for anxiety and treatment-as-usual. Participants were evaluated for symptom severity and family accommodation at pre- and post-treatment.Results: Results indicated that clinician-rated anxiety severity and parent-rated externalizing behaviors and autism spectrum disorder severity significantly predicted pre-treatment accommodation. Accommodation significantly decreased from pre- to post-treatment and non-responders showed significantly higher accommodation at post-treatment compared to responders. Finally, youth with higher pre-treatment accommodation had higher post-treatment anxiety.Conclusions: Findings indicate that accommodation for anxiety is common among youth with autism spectrum disorder and anxiety. Furthermore, accommodation is implicated in treatment outcomes and should be targeted in treatment for youth with autism spectrum disorder and anxiety.

The Pediatric Accommodation Scale: Psychometric Evaluation of a Therapist-Report Format.

Anxiety disorders are the most common mental health problem in youth, and accommodation is prevalent among youth with anxiety disorders. The Pediatric Accommodation Scale (PAS) is an interview administered by trained evaluators and a parent-report form (PAS-PR) to assess accommodation and its impact. Both have strong psychometric properties including internal consistency, inter-rater reliability, and data supporting construct validity. The present study evaluates the Pediatric Accommodation Scale - Therapist Report (PAS-TR), a therapist-reported version of the PAS-PR. Participants were 90 youth enrolled in cognitive behavioral therapy for anxiety. Therapists completed the PAS-TR over 16 therapy sessions. Internal consistency at baseline, convergent validity, divergent validity, and parent-therapist agreement were evaluated. Results suggest that the PAS-TR has mixed psychometric qualities suggesting that while not strong prior to the initiation of treatment, the PAS-TR may be a useful measure for therapists to rate accommodation as treatment progresses. Implications for assessment, treatment, and research are discussed.

Precision Implementation: An Approach to Mechanism Testing in Implementation Research.

Advancing mechanism-focused research in implementation science is a priority given its potential to improve tailoring and efficiency of implementation strategies. Experimental therapeutics, or experimental medicine, offers an approach for mechanism testing that has been promoted by the NIH Science of Behavior Change and endorsed by the National Institute for Mental Health. This approach has been applied across the translational spectrum - with initial applications to biological research and more recent applications to psychosocial treatment development research. We describe further advancement of experimental therapeutics along the translational spectrum and describe how it is ideally suited to inform precision experimental tests of implementation strategy mechanisms, which we term precision implementation. Such an approach to mechanism testing will allow for identification of causal dose-response relationships between implementation strategies, presumed mechanisms, and implementation outcomes. We discuss the tension between the scientific rigor required to conduct mechanism-focused research using experimental therapeutics and the "real world" conditions in which implementation research takes place. We provide a series of example studies that show "beginning to end" application of this framework in research focused on provider implementation of an evidence-based intervention in routine clinical care settings.

It's all in the name: why exposure therapy could benefit from a new one.

Exposure therapy for anxiety and related disorders is the psychological intervention with the strongest support for its efficacy and effectiveness to date. Yet, it is the least used evidence-based intervention in routine clinical practice, with a long-acknowledged public relations problem. Despite a wealth of research aimed at improving uptake of exposure, exposure's marketing and branding remains an untapped target. We first introduce principles from the marketing literature to propose that the field take steps toward a rebranding and repackaging of exposure therapy to support efforts to implement it widely. Second, we present preliminary data on clinician preferences for the use of alternative terminology developed to be more palatable and marketable - "Supported Approach of Feared Experiences - Cognitive Behavioral Therapy (SAFE-CBT)" - compared to traditional terminology. This initial survey indicated that most clinicians preferred use of the SAFE-CBT term when talking to patients, whereas only a minority preferred it for use among training clinicians. We conclude by discussing implications of these results for future efforts to implement exposure therapy more widely and set an agenda for future research in this space.

Applying computational modeling to assess age-, sex-, and strategy-related differences in Spin the Pots, a working memory task for 2- to 4-year-olds.

Working memory (WM) develops rapidly during early childhood. In the present study, visual WM (VSM) was measured using the well-established Spin the Pots task (Hughes & Ensor, 2005), a complex non-verbal eight-location object occlusion task. A self-ordered hiding procedure was adopted to allow for an examination of children's strategy use during a VWM task. Participants (N = 640) between the ages of 2 and 4 years were tested under semi-naturalistic conditions, in the home or in a museum. Computational modeling was used to estimate an expected value for the total trials to complete Spin the Pots via a random search and child performance was compared to expected values. Based on this approach, we determined that children who found six stickers retrieved them in significantly fewer trials than the expected value, excluding chance performance and implicating VWM. Results also showed age-related and sex-related changes in VWM. Between 2 and 4 years of age, 4-year-olds performed significantly better than younger children and girls out-performed the boys. Spontaneous use of a color matching hiding strategy was associated with a higher success rate on the task. Implications of these findings for early development of VWM are discussed.

Benefits provided by four ectomycorrhizal fungi to Pinus taeda under different external potassium availabilities.

Ectomycorrhizal fungi contribute to the nutrition of many woody plants, including those in the Pinaceae family. Loblolly pine (Pinus taeda L.), a native species of the Southeastern USA, can be colonized by multiple species of ectomycorrhizal fungi. The role of these symbionts in P. taeda potassium (K+) nutrition has not been previously investigated. Here, we assessed the contribution of four ectomycorrhizal fungi, Hebeloma cylindrosporum, Paxillus ammoniavirescens, Laccaria bicolor, and Suillus cothurnatus, in P. taeda K+ acquisition under different external K+ availabilities. Using a custom-made two-compartment system, P. taeda seedlings were inoculated with one of the four fungi, or kept non-colonized, and grown under K+-limited or -sufficient conditions for 8 weeks. Only the fungi had access to separate compartments in which rubidium, an analog tracer for K+, was supplied before harvest. Resulting effects of the fungi were recorded, including root colonization, biomass, and nutrient concentrations. We also analyzed the fungal performance in axenic conditions under varying supply of K+ and sodium. Our study revealed that these four ectomycorrhizal fungi are differentially affected by external K+ and sodium variations, that they are not able to provide similar benefits to the host P. taeda in our growing conditions, and that rubidium may be used with some limitations to estimate K+ transport from ectomycorrhizal fungi to colonized plants.

The Role of Comorbid Depression in Youth Anxiety Treatment Outcomes.

Findings have been mixed regarding the relationship between comorbid depression and anxiety and treatment outcomes for anxious youth. The current study compared a sample of anxious youth with a comorbid depressive disorder (n = 20) and those without comorbid depression (n = 137). All participants received 16 weekly sessions of Coping Cat and completed measures assessing anxiety/depression severity, impairment, and functioning at pretreatment and posttreatment. Results indicated that anxiety-focused CBT is efficacious for anxious youth with and without comorbid depressive disorders, with a higher rate of symptom improvement for youth with comorbid depression during treatment. However, comorbid depression was associated with higher severity at baseline and after treatment. Thus, despite the higher rate of symptom improvement, anxious youth with comorbid depression may benefit from additional treatment to address remaining symptoms.

Antidepressant Use in a 3- to 12-Year Follow-up of Anxious Youth: Results from the CAMELS Trial.

The current study explored whether patient characteristics predicted patterns of antidepressant use (i.e., never used, single episode of use, or two or more episodes) in a naturalistic follow-up. Participants in the child/adolescent multimodal (CAMS) extended long-term study. (n = 318) indicated medication use over the course of eight follow-up visits, 3-12 years after receiving treatment in CAMS. 40.6% of participants reported never using an antidepressant during follow-up, 41.4% reported a single episode of antidepressant use, and 18.0% reported multiple episodes of antidepressant use. Greater baseline anxiety severity marginally predicted a single episode of antidepressant use; baseline depression severity predicted multiple episodes of use. Reasons for discontinuing antidepressants included perceived ineffectiveness (31.8%), side effects (25.5%), and improvement in symptoms (18.5%). Exploratory analyses examined predictors of medication use. Findings suggest that antidepressant use is common among anxious youth, as is discontinuation of antidepressant use. Clinical implications and future directions are discussed.

Identifying the organizational innovation-specific capacity needed for exposure therapy.

BACKGROUND: Current approaches to increasing the rates of clinician use of exposure therapy for anxiety disorders in community settings are limited. Research underscores the importance of addressing contextual variables to facilitate clinician use of evidence-based practices; however, no studies have identified the innovation-specific organizational capacity necessary to implement exposure therapy. Such work is critical to ensure that treatment-seeking individuals with anxiety receive effective care. METHODS: We used a two-step process to identify the innovation-specific organizational capacity necessary to deliver exposure. First, 24 leaders of specialty anxiety clinics in the United States (50% female, mean [M]age = 47.7 years) completed a survey about the organizational innovation-specific capacity (e.g., policies and procedures) they employ to support their providers in delivering exposure therapy. Second, 19 community clinicians (79% female, M age = 42.9 years) reported on the extent to which these characteristics were present in their settings. RESULTS: In Step 1, specialty clinic leaders unanimously endorsed six organizational characteristics as essential and five as important within the areas of organizational policies, supervisory support, and peer clinician support. These characteristics were present in more than 90% of specialty clinics. In Step 2, therapists in community clinics reported these characteristics were minimally present in their organizations. CONCLUSIONS: Specialty clinic leaders exhibited consensus on the innovation-specific organizational capacity necessary to implement exposure therapy. Identified characteristics were largely absent from community clinics. Developing fiscal, policy, or organizational strategies that enhance the organizational capacity within community settings may improve the patients' access to effective treatment for anxiety disorders.

Parent Preferences and Experiences with Psychological Treatment: Results from a Direct-to- Consumer Survey using the Marketing Mix Framework.

Direct-to-consumer (DTC) marketing strategies represent an increasingly popular approach to promote patient awareness of psychological treatments (PTs). The Marketing Mix is a well-established framework used to inform marketing decisions consisting of four "P's": Product (or Service), Promotion, Place, and Price. We conducted the first DTC marketing survey using the Marketing Mix framework to explore how parents concerned about their adolescents' behavioral health receive information about PTs. A sample of 411 parents (51% girls, 82% Non-Hispanic White) of 12- to 19-year-old adolescents completed an online survey asking how they would prefer to receive information about PTs, including five questions spanning the Promotion, Price, and Place dimensions of The Marketing Mix. A subsample of 158 parents also reported on how they had received PT information during their adolescent's most recent therapy experience, allowing us to compare ideal versus actual therapy experiences. We explored the extent to which experiences varied as a function of parent race/ethnicity, income per capita, parent education level, and adolescent treatment history. Bivariate analyses and multivariate logistic regressions were used to examine which of these variables were associated with parents' responses to specific survey items. Analyses revealed that parent preferences varied as a function of income per capita, education level, and history of treatment. In addition, there were significant gaps between parents' ideal and most recent therapy experiences. Implications for the marketing of PTs are discussed.

Locked in and left out: the "prison penalty" for implementation of evidence-based interventions.

BACKGROUND: While the broader medical community grapples with the widely accepted notion that it takes an average of 17 years for research evidence to be incorporated into clinical practice, the implementation of evidence-based interventions in carceral settings (i.e., jails and prisons) faces longer delays, exacerbating health disparities. MAIN BODY: The "prison implementation penalty" describes the significant delay in and limited adoption of evidence-based healthcare practices in carceral settings. We explore the complex challenges of implementing evidence-based interventions in jails and prisons, environments where healthcare often plays a secondary role under security and discipline. We use specific frameworks to highlight the unique barriers within these settings and propose potential implementation strategies. These challenges have broad implications for health equity due to the disproportionate impact on the marginalized groups affected by mass incarceration. Implementation science has potential to mitigate these disparities. CONCLUSION: Bridging the gap between healthcare evidence and practice in carceral settings offers a public health opportunity. Implementation science offers a unique role in improving healthcare standards and reducing health inequities in this environment.

The education of experience: Mixed methods evidence demonstrates the benefit of multiparity.

PROBLEM: Existing quantitative data is conflicting concerning whether multiparous birthing parents (individuals with an older child(ren)) experience an easier postpartum transition compared to primiparous birthing parents (first time parents). AIM: This convergent mixed methods study leverages the depth of qualitative inquiry to seek a clearer understanding of the way in which acquired parenting experience contributes to observed quantitative differences in outcomes between parity groups. This work can serve as a first step in planning for supportive interventions that effectively address the postpartum needs of both parity groups. METHODS: Thirty birthing parents (43.3% multiparous; 46.7% racial minorities) completed measures of postpartum functioning, perceived stress, anxiety symptoms, and depression symptoms as well as an interview inquiring about factors impacting postpartum functioning. Scores on postpartum functioning and emotional wellbeing were compared between parity groups, and these findings were merged with the qualitative data on firsthand parenting experience to clarify how acquired experience impacts functioning and emotional wellbeing during the postpartum transition. FINDINGS: Primiparous parents reported significantly: worse postpartum functioning, higher perceived stress, higher levels of depression symptoms, and higher levels of anxiety symptoms. Participants' qualitative report of how acquired parenting experience impacts wellbeing suggests that experience grants parents skills, knowledge, and the opportunity to disconfirm maladaptive cognitions about parenting which allows for increased comfort and confidence in the parental role. CONCLUSIONS: The practical and psychological resources gained from acquiring parenting experience during one's first postpartum period appear to be brought forward into subsequent pregnancies and protect against threats to functioning and emotional wellbeing.

Mindfulness-Based Stress Reduction Health Insurance Coverage: If, How, and When? An Integrated Knowledge Translation (iKT) Delphi Key Informant Analysis.

Objectives: Hundreds of trials have evaluated Mindfulness-Based Stress Reduction (MBSR), but in the United States, it is generally not covered by health insurance. Consequently, the aims were to identify the following: (1) key questions to make decisions about if, how, and when MBSR should be covered by health insurance; (2a) barriers and (2b) facilitators to understand and resolve for MBSR to be covered by health insurance; and (3) highest priority evidence needed to inform health insurance coverage decisions. Methods: Key informants (n = 26) included health insurers, healthcare administrators, policymakers, clinicians, MBSR instructors, and MBSR students. An initial pool of items related to the study aims was generated through qualitative interviews. Through the Delphi process, participants rated, discussed, and re-rated each item's relevance. Items were required to reach a consensus of ≥ 80% agreement to be retained for final inclusion. Results: Of the original 149 items, 42 (28.2%) met the ≥ 80% agreement criterion and were retained for final inclusion. The most highly rated items informing whether MBSR should be covered by health insurance included research demonstrating that MBSR works and that it is not harmful. The most highly rated barriers to coverage were that MBSR is not a medical treatment and patient barriers to attendance. Highly rated facilitators included the potential of MBSR to address common mental health and psychosomatic problems. Finally, understanding what conditions are effectively treated with MBSR and the impact of MBSR on stress were rated as the highest priority evidence needed to inform health insurance coverage decisions. Conclusions: Findings highlight priorities for future research and policy efforts to advance health insurance coverage of MBSR in the United States. Supplementary Information: The online version contains supplementary material available at 10.1007/s12671-024-02366-x.

Developing and testing a produce prescription implementation blueprint to improve food security in a clinical setting: a pilot study protocol.

BACKGROUND: Food insecurity is common in the United States, especially in Rhode Island, where it affects up to 33% of residents. Food insecurity is associated with adverse health outcomes and disproportionally affects people from minoritized backgrounds. Produce prescription programs, in which healthcare providers write "prescriptions" for free or reduced cost vegetables, have been used to address food insecurity and diet-related chronic disease. Although there is growing evidence for the effectiveness of produce prescription programs in improving food security and diet quality, there have been few efforts to use implementation science methods to improve the adoption of these programs. METHODS: This two-phase pilot study will examine determinants and preliminary implementation and effectiveness outcomes for an existing produce prescription program. The existing program is funded by an Accountable Care Organization in Rhode Island and delivered in primary care practices. For the first phase, we conducted a formative evaluation, guided by the Consolidated Framework for Implementation Research 2.0, to assess barriers, facilitators, and existing implementation strategies for the produce prescription program. Responses from the formative evaluation were analyzed using a rapid qualitative analytic approach to yield a summary of existing barriers and facilitators. In the second phase, we presented our formative evaluation findings to a community advisory board consisting of primary care staff, Accountable Care Organization staff, and staff who source and deliver the vegetables. The community advisory board used this information to identify and refine a set of implementation strategies to support the adoption of the program via an implementation blueprint. Guided by the implementation blueprint, we will conduct a single-arm pilot study to assess implementation antecedents (i.e., feasibility, acceptability, appropriateness, implementation climate, implementation readiness), implementation outcomes (i.e., adoption), and preliminary program effectiveness (i.e., food and nutrition security). The first phase is complete, and the second phase is ongoing. DISCUSSION: This study will advance the existing literature on produce prescription programs by formally assessing implementation determinants and developing a tailored set of implementation strategies to address identified barriers. Results from this study will inform a future fully powered hybrid type 3 study that will use the tailored implementation strategies and assess implementation and effectiveness outcomes for a produce prescription program. TRIAL REGISTRATION: Clinical trials: NCT05941403 , Registered June 9, 2023.