Developing the Workforce of the Digital Future: mHealth Competency and Fidelity Measurement in Community-Based Care.

Integrating mobile health (mHealth) interventions into settings that serve diverse patient populations requires that prerequisite professional competencies are delineated and that standards for clinical quality assurance can be pragmatically assessed. Heretofore, proposed mHealth competencies have been broad and have lacked a framework to support specific applications. We outline the meta-competencies identified in the literature relevant to mHealth interventions and demonstrate how these meta-competencies can be integrated with population- and intervention-related competencies to help guide a pragmatic approach to competency assessment. We present a use case based on FOCUS-an evidence-based mHealth intervention designed for individuals with serious mental illness and currently being implemented in geographically and demographically diverse community behavioral health settings. Subsequent to identifying the cross-cutting competencies relevant to the target population (outpatients experiencing psychotic symptoms), substratal intervention (Cognitive Behavioral Therapy for psychosis), and treatment modality (mHealth), we detail the development process of an mHealth fidelity monitoring system (mHealth-FMS). We adhered to a published sequential 5-step process to design a fidelity monitoring system that aligns with our integrated mHealth competency framework and that was guided by best practices prescribed by the Treatment Fidelity Workgroup of the National Institutes of Health Behavior Change Consortium. The mHealth-FMS is intended to enhance both clinical and implementation outcomes by grounding the mHealth interventionist and the system of care in which they operate in the core functions, tasks, knowledge, and competencies associated with system-integrated mHealth delivery. Future research will explore acceptability and feasibility of the mHealth-FMS.

Cost of Implementing mHealth in Community Mental Health Settings: External Versus Internal Facilitation.

OBJECTIVE: This study aimed to compare the costs of two implementation models for the mobile health (mHealth) intervention FOCUS in community mental health settings. The external facilitation (EF) approach uses a hub-and-spoke model, in which a central specialist provides support to clinicians and clients at multiple agencies. With the internal facilitation (IF) approach, frontline clinical staff at each center are trained to serve as their organization's local specialists. METHODS: Financial and economic cost data were collected in the context of a hybrid type 3 effectiveness-implementation trial by using a mixed-methods, top-down expenditure analysis with microcosting approaches. The analysis compared the incremental costs of both models and the costs of successfully engaging clients (N=210) at 20 centers. Costs were characterized as start-up or recurrent (personnel, supplies, contracted services, and indirect costs). RESULTS: The average annual financial cost per site was $23,517 for EF and $19,118 for IF. EF yielded more FOCUS users at each center, such that the average monthly financial costs were lower for EF ($167 per client [N=129]) than for IF ($177 per client [N=81]). When using a real-world scenario based on economic costs and a lower organizational indirect rate, the average monthly cost per client was $73 for EF and $59 for IF. Both models reflected substantial cost reductions (about 50%) relative to a previous deployment of FOCUS in a clinical trial. CONCLUSIONS: Compared with IF, EF yielded more clients who received mHealth at community mental health centers and had comparable or lower costs.

Examining Potential Barriers to mHealth Implementation and Engagement in Schizophrenia: Phone Ownership and Symptom Severity.

Objective: Implementation of mobile health (mhealth) interventions remains limited among those with schizophrenia. This study examined several logistical barriers to the implementation of mHealth interventions, particularly text message interventions, for people with schizophrenia. Methods: This study examined the feasibility of leveraging personal mobile phones to deliver mHealth interventions by using data from a pilot randomized controlled trial (RCT) of a text message intervention delivered on personal mobile phones to 56 people with schizophrenia with motivation reductions. Results: Among those screened for the RCT (n =100), 91% had a mobile phone. For randomized participants (n = 56), 82.1% had a smartphone, with almost all (93.5%) having an Android processing system. Most randomized participants had unlimited text messages (96.4%) or voice calls (76.8%) with their mobile service plan, with 32.1% having unlimited data each month. At baseline, most used text messages (85.2%) and the internet (59.3%), while fewer participants used mobile applications (35.2%) at least once a week. Finally, there were no significant associations between engagement in the text message intervention and participant demographics, symptoms (positive, mood, negative), neurocognition, or mobile phone or plan characteristics or changes made during the 8 week intervention. Conclusions: Even those with schizophrenia with perceived symptom barriers to mHealth engagement (i.e., motivation reductions) may have access to mobile phones and plans and familiarity with mobile features to engage meaningfully with a text message intervention. These results help to support future implementations of text message interventions, which may enhance the provision of care for those with schizophrenia.

Community Mental Health Care Delivery During the COVID-19 Pandemic: Practical Strategies for Improving Care for People with Serious Mental Illness.

The COVID-19 pandemic has presented a formidable challenge to care continuity for community mental health clients with serious mental illness and for providers who have had to quickly pivot the modes of delivering critical services. Despite these challenges, many of the changes implemented during the pandemic can and should be maintained. These include offering a spectrum of options for remote and in-person care, greater integration of behavioral and physical healthcare, prevention of viral exposure, increased collaborative decision-making related to long-acting injectable and clozapine use, modifying safety plans and psychiatric advance directives to include new technologies and broader support systems, leveraging natural supports, and integration of digital health interventions. This paper represents the authors' collaborative attempt to both reflect the changes to clinical practice we have observed in CMHCs across the US during this pandemic and to suggest how these changes can align with best practices identified in the empirical literature.

Effectiveness of the Intent to Complete and Intent to Attend Intervention to Predict and Prevent Posttraumatic Stress Disorder Treatment Drop Out Among Soldiers.

Active duty military service members have high dropout rates for trauma-focused treatment in both clinical practice and research settings. Measuring patients' intent to complete (ITC) and intent to attend (ITA) treatment have been suggested as methods to reduce dropout, but no studies have examined the effectiveness of such measures. In an attempt to reduce high dropout rates, measures of ITC and ITA were included in a randomized controlled trial evaluating prolonged exposure (PE) and virtual reality exposure (VRE) in active duty soldiers with posttraumatic stress disorder (PTSD). Participants (N = 108) were randomized to either PE or VRE, and the last 49 to enroll were administered a measure of ITC at enrollment and a measure of ITA at the end of every session. A score of 7 or below triggered a problem-solving discussion with the individual's therapist. The results revealed that the ITA assessment predicted treatment dropout after controlling for mental health stigma, PTSD symptoms, and age, odds ratio (OR) = 0.24, p = .023. Additionally, participants who completed the ITA assessment were less likely to drop out than those who were not administered the ITA, OR = 0.29 p = .002. The ITC did not predict treatment dropout OR = 0.98, p = .402. These findings suggest that assessing ITA throughout trauma-focused therapy may reduce treatment dropout rather than solely measuring ITC prior to starting psychotherapy. Based on these preliminary findings, future research should randomize the measurement of ITA in clinical trials to evaluate its impact on treatment dropout.

Spanish Abstracts by Asociación Chilena de Estrés Traumático (ACET) La efectividad de la intención de completar y la intención de asistir a la intervención para predecir y prevenir el abandono del tratamiento para el TEPT del soldado INTENCIÓN DE ASISTIR A LA TERAPIA DE EXPOSICIÓN PARA EL TEPT Los miembros del servicio militar en servicio activo tienen altas tasas de abandono del tratamiento centrado en el trauma, tanto en la práctica clínica como en la investigación. La medición de la intención de los pacientes de completar el tratamiento (ITC en su sigla en inglés) y la intención de asistir (ITA en su sigla en inglés) se han sugerido como métodos para reducir el abandono, pero ningún estudio ha examinado la efectividad de tales medidas. En un intento por reducir las altas tasas de abandono, se incluyeron medidas de la ITC y la ITA en un ensayo controlado aleatorio que evaluaba la exposición prolongada (PE en su sigla en inglés) y la exposición de realidad virtual (VRE en su sigla en inglés) en soldados en servicio activo con trastorno de estrés postraumático (TEPT). Los participantes (N = 108) fueron asignados al azar a PE o VRE, y a los últimos 49 que se inscribieron se les administró una medida de ITC al momento de la inscripción y una medida de ITA al final de cada sesión. Un puntaje de 7 o menos desencadenó una discusión de resolución de problemas con el terapeuta del individuo. Los resultados revelaron que la evaluación ITA predijo el abandono del tratamiento después de controlar el estigma de salud mental, los síntomas del TEPT y la edad, razón de probabilidades (OR) = 0.24, p = .023. Además, los participantes que completaron la evaluación ITA tenían menos probabilidades de abandonar que aquellos que no recibieron la ITA, OR = 0.29, p = .002. El ITC no predijo el abandono del tratamiento OR = 0.98, p = .402. Estos hallazgos sugieren que evaluar la ITA a lo largo de la terapia centrada en el trauma puede reducir el abandono del tratamiento en lugar de solo medir el ITC antes de comenzar la psicoterapia. En base a estos hallazgos preliminares, la investigación futura debe aleatorizar la medición de ITA en ensayos clínicos para evaluar su impacto en el abandono del tratamiento.

Revisiting the validity of measures of social cognitive bias in schizophrenia: Additional results from the Social Cognition Psychometric Evaluation (SCOPE) study.

OBJECTIVE: The ongoing Social Cognition Psychometric Evaluation (SCOPE) study is in the process of forming a gold-standard battery of social cognition tests for use in clinical trials. Previous SCOPE phases have not acknowledged key differences between social cognition skills and biases, and psychometric validity analyses might provide important information if tailored to bias-related outcomes. This study aims to validate these measures with such bias-related outcomes. METHODS: Two measures of social cognitive bias - the Ambiguous Intention Hostility Questionnaire (AIHQ; hostile attribution bias) and Trustworthiness Task (distrust bias) - were reviewed according to their relationships to (1) current and prospective symptom levels, (2) questionnaires of trait paranoia and hostility and informant-rated hostility, (3) interpersonal conflict, as well as (4) relationships to measures of trait paranoia, hostility, and interpersonal conflict above and beyond the influence of clinically rated symptoms. RESULTS: Results supported hypotheses that social cognitive bias provides information about cognition, symptoms, and functioning related to interpersonal conflict. Each bias demonstrated relationships to trait paranoia questionnaires, hostility, or interpersonal conflict outcomes, and these persisted above and beyond the influence of clinically rated symptoms. Hostile attribution bias also predicted change in symptom levels over a brief interval. CONCLUSIONS: Overall, the current bias-specific psychometric analysis provides support for continued study of social cognitive biases. PRACTITIONER POINTS: Hostile attribution bias may play a role in important outcome variables given relationships to emotional discomfort and suspiciousness symptoms, trait paranoia and hostility, interpersonal conflict, as well as prospective hostility symptoms. Distrust bias may also impact real-world functioning, as it is related to hostility, suspiciousness, and positive symptoms, trait paranoia, and hostility. Relationships of social cognitive biases to interpersonal conflict outcomes exist independently of interview-rated symptoms and persist above and beyond the influence of social cognitive skills, which appear to demonstrate weaker relationships to these outcomes. Understanding and assessing the individual's biases towards distrust or blame might help practioners predict interpersonal conflict and future increases in symptoms.

Social cognition in schizophrenia: factor structure, clinical and functional correlates.

BACKGROUND: Social cognition is consistently impaired in people with schizophrenia, separable from general neurocognition, predictive of real-world functioning and amenable to psychosocial treatment. Few studies have empirically examined its underlying factor structure. AIMS: This study (1) examines the factor structure of social cognition in both a sample of individuals with schizophrenia-spectrum disorders and non-clinical controls and (2) explores relationships of factors to neurocognition, symptoms and functioning. METHOD: A factor analysis was conducted on social cognition measures in a sample of 65 individuals with schizophrenia or schizoaffective disorder, and 50 control participants. The resulting factors were examined for their relationships to symptoms and functioning. RESULTS: Results suggested a two-factor structure in the schizophrenia sample (social cognition skill and hostile attributional style) and a three-factor structure in the non-clinical sample (hostile attributional style, higher-level inferential processing and lower-level cue detection). In the schizophrenia sample, the social cognition skill factor was significantly related to negative symptoms and social functioning, whereas hostile attributional style predicted positive and general psychopathology symptoms. CONCLUSIONS: The factor structure of social cognition in schizophrenia separates hostile attributional style and social cognition skill, and each show differential relationships to relevant clinical variables in schizophrenia.

Relationship between olfactory function and social cognition in euthymic bipolar patients.

OBJECTIVE/INTRODUCTION: There is a close functional and neuroanatomical relationship between olfactory ability and emotional processing. The present study seeks to explore the association between olfactory ability and social cognition, especially facial emotion perception, in euthymic bipolar patients. METHODS: Thirty-nine euthymic outpatients meeting DSM-IV-TR criteria for bipolar disorder and 40 healthy volunteers matched on socio-demographic criteria were recruited. Both groups were assessed at one time point with the University of Pennsylvania Smell Identification Test (UPSIT), the Emotion Recognition Test, and The Faux Pas Recognition Test, as well as measures of general cognition and functioning. RESULTS: The bipolar patients showed a significant impairment in olfactory identification (UPSIT) and social cognition measures compared to healthy controls. Analyses revealed significant relationships between olfactory identification and facial emotion recognition, theory of mind, general cognition, and a trend-level relationship with functioning. Controlling for age and cigarettes smoked, relationships remained significant between olfactory function and facial emotion recognition. CONCLUSION: There is a deficit of olfactory identification in euthymic patients with bipolar disorder that is correlated with a deficit in both verbal and non-verbal measures of social cognition.

Anhedonia in prolonged schizophrenia spectrum patients with relatively lower vs. higher levels of depression disorders: associations with deficits in social cognition and metacognition.

This study has sought to explore whether there are at least two subtypes of anhedonia in schizophrenia: one closely linked with depression and another that occurs in the absence of depression which is related to a general paucity of internal experience. Participants were 163 adults with schizophrenia who completed assessments of depression, anhedonia, executive functioning, positive and negative symptoms, social cognition and metacognition. A cluster analysis based on participants' depression and anhedonia symptom scores produced three groups: High Depression/High Anhedonia (n=52), Low Depression/Low Anhedonia (n=52), and Low Depression/High Anhedonia (n=59). An ANCOVA and post hoc comparisons controlling for positive and negative symptoms found that the Low Depression/High Anhedonia group had poorer metacognition and social cognition than other groups. These findings point to the possibility of a subtype of anhedonia in schizophrenia, one occurring in the relative lesser levels of depression, and tied to deficits in the ability to think about oneself and others.

How is the Beads Task related to intolerance of uncertainty in anxiety disorders?

Intolerance of uncertainty (IU) is a cognitive bias associated with anxiety disorders that has only been reliably measured using self-report instruments. The current study investigated relationships between a probabilistic inference task - the Beads Task - and self-report IU. Individuals with anxiety disorders (ANX) and non-anxious controls (NAC) completed self-report measures as well as the Beads Task at three levels of difficulty. The Beads Task successfully induced task-related uncertainty as the decision became more difficult. While the two groups did not differ on the observable performance related measures, the ANX group was significantly more distressed during the task than were the NACs. Moreover, among the ANX group, self-reported IU was correlated with draws to decision and distress during the task. The Beads Task appears to provoke distress associated with uncertainty for anxious individuals, rather than altering their behavioral responses; thus, clinical implications and avenues for future research are discussed.