Standardizing Fidelity to Evidence-Based Practice in the Early Psychosis Intervention Network.

OBJECTIVE: This study investigated variations in the measurement of fidelity to coordinated specialty care (CSC) within the Early Psychosis Intervention Network (EPINET), a learning health system that consists of 101 CSC programs within eight hubs. The study investigated the degree to which five fidelity scales could be mapped onto a standard scale. METHODS: The investigators identified six fidelity scales in use by EPINET participants; examined their item content, scoring, and data sources; and mapped five scales onto the First Episode Psychosis Services Fidelity Scale (FEPS-FS), which is the most widely used scale. RESULTS: Mapping five fidelity scales onto the FEPS-FS showed that the percentage of FEPS-FS components successfully mapped ranged from 42% to 81%. CONCLUSIONS: Mapping five scales onto one that uses dichotomous scoring identified the degree of variation in measures and reduced the amount and quality of usable fidelity data. Identifying variations in fidelity measurement is a core function of a learning health system.

Community- and Program-Level Predictors of Funding Streams Used by Coordinated Specialty Care Programs.

OBJECTIVE: Although coordinated specialty care (CSC) is an effective service model to address first-episode psychosis, CSC is not widely accessible in the United States, and funding for this service model often remains challenging. The authors examined whether community- or program-level factors predict the use of public and private funding streams in a national sample of 34 CSC programs in 22 U.S. states and territories. METHODS: As part of a larger mixed-methods study, CSC program leaders completed a brief questionnaire regarding funding sources. Statistical modeling was used to examine program- and community-level predictors of the use of funding sources. RESULTS: Most CSC programs (20 of 34, 59%) reported that Mental Health Block Grant (MHBG) set-aside funds accounted for more than half of their total funding, and 11 of these programs reported that these funds contributed to >75% of their funding. Programs ≤5 years old were more likely to rely on MHBG set-aside funds. Programs in Medicaid expansion states were more likely to rely on Medicaid funding than programs in nonexpansion states. Programs in higher-income service catchment areas used more state funds than did those in lower-income areas, and among programs in lower-income service catchment areas, those that were >4 years old were more likely than those ≤4 years old to rely on state funds other than Medicaid. CONCLUSIONS: CSC programs remain largely dependent on MHBG set-aside funding. Some programs have diversified their funding streams, most notably by including more Medicaid and other state funding. A more comprehensive funding approach is needed to reduce reliance on the MHBG set-aside funds.

Cycles of reform in the history of psychosis treatment in the United States.

The history of psychosis treatment follows a series of four cycles of reform which provide a framework for understanding mental health services in the United States. The first three cycles of reform promoted the view that early treatment of mental disorders would reduce chronic impairment and disability. The Moral Treatment era (early 1800's to 1890) featured freestanding asylums, the Mental Hygiene movement (1890 to World War II) introduced psychiatric hospitals and clinics, and the Community Mental Health Reform period (World War II to late 1970's) produced community mental health centers. None of these approaches succeeded in achieving the disability-prevention goals of early treatment of psychosis. The fourth cycle, the Community Support Reform era (late 1970's to the present) shifted the focus to caring for those already disabled by a mental disorder within their communities and using natural support systems. This shift embraced a broader social welfare framework and included additional services and supports, such as housing, case management, and education. Psychosis became more central during the current Community Support Reform era partly because individuals with psychosis continued to have disabling life experiences despite efforts at reform. Some degree of recovery from psychosis is possible, and individuals with serious impairment may move towards social integration and community participation. Early intervention for young people with psychosis focuses on reducing the negative sequelae of psychosis and promotes recovery-oriented changes in service delivery. The role of social control, the involvement of service users and their families, and the balance between psychosocial and biomedical treatments play an important role in this history. This paper describes the reform cycles, their political and policy contexts, and what influenced its successes and shortcomings.

State Mental Health Authority Level of Involvement in Coordinated Specialty Care Clinics and Client Outcomes.

OBJECTIVE: State mental health authorities (SMHAs) in all U.S. states and territories administer the Mental Health Block Grant (MHBG) set-aside funding for first-episode psychosis. Funds support implementation of coordinated specialty care (CSC) programs. The authors investigated the relationship between the level of SMHA involvement with CSC programs and clinical outcomes of clients in these programs. METHODS: As part of a mixed-methods study of 34 CSC programs, SMHAs from 21 states and one U.S. territory associated with the 34 CSC programs participated in a 1-hour interview (between November 2018 and May 2019) focused on SMHA involvement in administration of MHBG set-aside funds and the SMHA's ongoing relationship with funded CSC programs. SMHA involvement was rated on a scale of 1 to 5, with 5 indicating the highest involvement. Client outcome data were collected at the 34 study sites over an 18-month period. Multilevel random-effect modeling was used, controlling for response propensity (propensity score), client demographic variables, and program-level covariates (i.e., fidelity score, staff turnover rates, service area urbanicity, and number of clients enrolled). RESULTS: Clients in CSC programs with SMHAs that were the most involved (level 5) had significantly improved symptoms, social functioning, and role functioning, compared with clients in programs with which SMHAs were least involved (level 1). CONCLUSIONS: The findings suggest that increased SMHA involvement in CSC programs is relevant for positive client outcomes. Levels of first-episode psychosis funding doubled in 2021 and 2022, and it is important to identify how SMHAs affect the success of CSC programs and the individuals served.

Client Racial Composition in First-Episode Psychosis Programs Compared With Compositions in Program Service Areas.

OBJECTIVE: The authors examined the extent to which clients served by first-episode psychosis programs reflected the racial composition of the surrounding service area and, to the extent that they did not, explored possible explanatory factors. METHODS: As part of a national study of coordinated specialty care (CSC) sites in the United States, 35 programs documented race for 772 clients. Programs identified a geographic service area for their clients. Using Census data, the authors identified the proportion of clients in this service area who were Black and then examined the extent of disproportionality, calculated as a risk ratio and as a relative difference in racial composition between CSC programs and their service areas. RESULTS: Overall, 71% of CSC programs had a disproportionately greater proportion of Black clients than Black residents within the service area. This disproportionality was still evident after conducting sensitivity analyses that included adjusting for sampling error in the service area population estimates; however, smaller study sites displayed greater fluctuations in disproportionality in the sensitivity analyses. CONCLUSIONS: Using data from diverse CSC programs, the authors illustrate that the odds of Blacks receiving services through a CSC program are much higher than would be expected on the basis of the population living in the area being served by the program. Multiple reasons may explain this finding, but in the absence of clear explanatory factors, this result may be ripe for discussion and further investigation.

Growth of Coordinated Specialty Care in the United States With Changes in Federal Funding Policies: 2014-2018.

OBJECTIVE: In 2014, the number of coordinated specialty care (CSC) programs in the United States greatly expanded. The proliferation of CSC programs was likely due in part to the availability of Mental Health Block Grant (MHBG) set-aside funds for treatment of first-episode psychosis. This study aimed to explore the characteristics of CSC programs across 44 states, the District of Columbia, and three U.S. territories that received funding through the MHBG set-aside program in 2018. METHODS: Leadership at 88% (N=215) of the 244 MHBG-funded CSC programs identified through state mental health authorities participated in an online survey. RESULTS: Overall, 69% of the CSC programs were initiated after 2014. More than 90% of programs included services that were consistent with federal guidance. CSC programs showed variability in training received, program size, and enrollment criteria. CONCLUSIONS: The results of this study emphasize that clear federal guidance can help shape national CSC implementation efforts, although decisions at the state and local levels can influence how implementation occurs. The strategy of states administering federal funds for CSC may be adapted for the rollout of other behavioral health interventions. Future studies could investigate factors that may shape national dissemination efforts, such as leadership within the state, funding, availability of programs established before the influx of funding, and considerations about sustainability after the funding is no longer available.

Paths Toward Sustainable State and County Systems of Care.

The Substance Abuse and Mental Health Services Administration's Children's Mental Health Initiative (CMHI) Cooperative Agreements support the development of children's systems of care (SOCs). The National Evaluation of CMHI interviewed representatives from Mental Health Authorities (MHA) and Medicaid agencies in 25 state, county, and municipal jurisdictions in the FY13 and FY14 grant cohorts in grant years 2 and 4. This paper analyzes funding for five services (wraparound planning; intensive care coordination; family peer support; youth peer support; and flexible funding) that are a core part of SOCs, and grantee descriptions of sustainability strategies and challenges. The analysis found that, of the five pathways described in the literature: securing Medicaid coverage; obtaining state MH system funding; braiding funding with other child-serving systems; modifying payment structures to support workforce development; and redeploying funds from higher cost to lower cost services, grantees most frequently used Medicaid coverage, often combined with MHA funding.

Family Organizations in Children's Mental Health Systems of Care: the Challenge of Maintaining Financial Sustainability.

Family-run organizations are an important source of support for families of children with serious emotional disturbance, yet little work has explored how these organizations sustain their work. The National Evaluation Team (NET) for the Substance Abuse and Mental Health Services Administration's Children's Mental Health Initiative grant program interviewed 20 family organizations in Grant Year 2 and 22 organizations in Year 4 to assess their main funding sources, the adequacy of this funding to support the organization, and changes in their funding and financial sustainability over time. Family organizations were supported mainly by mental health authority and other state agency funding and were in early stages of accessing Medicaid funding for peer services. However, many did not have sufficient or sustainable funding to maintain their functions by the grant's end. This work discusses factors that may relate to sustainability and the development of more sustainable funding for these important organizations.

First-Person Accounts of Change Among Young Adults Enrolled in Coordinated Specialty Care for First-Episode Psychosis.

OBJECTIVE: This study investigated how clients of a coordinated specialty care (CSC) program for first-episode psychosis perceived how they changed while attending the program, what the most important changes were, and what mechanisms they believed helped bring about these changes. METHODS: Study participants were 121 individuals (71 men and 50 women) from 35 CSC programs across 22 U.S. states. Responses to the primary questions of interest were procured through a semistructured interview. Data on the length of time in the CSC program were also obtained. The authors used systematic content analyses to analyze these qualitative data. RESULTS: Participants reported a greater number of changes the longer they had received CSC services. Half of the participants reported improved psychiatric symptoms, and this change was the most important for almost one-third (31%; N=32) of the sample. In addition, 39% (N=45) of participants also reported improved social and interpersonal skills, changes in their attitude to and perspective on life, and more treatment engagement. Participants most frequently endorsed therapy as the mechanism underlying their improvement. CONCLUSIONS: Standardized outcome measures allow systematic assessment of clinical and functional status, but they do not provide a nuanced understanding of the underlying mechanisms or the areas of improvement most important to individual clients. The findings reinforce the value of mixed methods in both research and quality improvement efforts as well as for greater integration of patient-selected outcome measures.

Coordinated Specialty Care Discharge, Transition, and Step-Down Policies, Practices, and Concerns: Staff and Client Perspectives.

OBJECTIVE: In recent years, optimizing the process of transition and discharge from coordinated specialty care (CSC), a program that provides early intervention in psychosis, has emerged as an important focus area for program administrators, clinicians, and policy makers. To explore existing CSC policies and practices and to understand frontline provider and client views on discharge, the authors conducted a comprehensive analysis of staff and client interview data from the Mental Health Block Grant 10% Set-Aside Study. METHODS: Data from 66 interviews with groups of CSC providers and administrators representing 36 sites and 22 states were analyzed, as well as data from interviews with 82 CSC clients at 34 sites. Transcripts were coded by using systematic content analyses. RESULTS: Analyses of data from providers and administrators showed the heterogeneity of CSC program practices and strategies regarding discharge and highlighted a range of concerns related to postdischarge service accessibility and quality. Analysis of data from client interviews reflected the heterogeneity of transition challenges that clients confront. A significant number of participants reported concerns about their readiness for discharge. CONCLUSIONS: CSC discharge policies and practices vary across CSC programs and states. Frequent clinician and client concerns about optimal program length, transition, and postdischarge services highlight the importance of sustained policy and research efforts to develop evidence-informed practice guidelines and possible modifications to the time-limited CSC model that currently dominates the field.

Randomized, Placebo-Controlled Trial of Methyl B12 for Children with Autism.

OBJECTIVE: Children with autism spectrum disorder (ASD) have been reported to have reduced ability to methylate DNA and elevated markers of oxidative stress. We sought to determine if methyl B12, a key metabolic cofactor for cellular methylation reactions and antioxidant defense, could improve symptoms of ASD. METHODS: A total of 57 children with ASD were randomly assigned to 8 weeks of treatment with methyl B12 (75 µg/kg) or saline placebo every 3 days in a subcutaneous injection. The primary outcome measure was overall improvement in symptoms of ASD as measured by the Clinical Global Impressions-Improvement (CGI-I) score. Secondary outcome measures included changes in the Aberrant Behavior Checklist (ABC) and the Social Responsiveness Scale (SRS). Laboratory measures of methionine methylation and antioxidant glutathione metabolism were assessed at baseline and 8 weeks. RESULTS: A total of 50 children (mean age 5.3 years, 79% male) completed the study. The primary outcome measure - the clinician rated CGI-I score - was statistically significantly better (lower) in the methyl B12 group (2.4) than in the placebo group (3.1) (0.7 greater improvement in the methyl B12 group, 95% CI 1.2-0.2, p = 0.005). Clinical improvement among children treated with methyl B12 was positively correlated with increases in plasma methionine (p = 0.05), decreases in S-adenosyl-l-homocysteine (SAH) (p = 0.007) and improvements in the ratio of S-adenosylmethionine (SAM) to SAH (p = 0.007), indicating an improvement in cellular methylation capacity. No improvements were observed in the parent-rated ABC or SRS. CONCLUSIONS: Methyl B12 treatment improved clinician-rated symptoms of ASD that were correlated with improvements in measures of methionine metabolism and cellular methylation capacity. Clinical Trial Registry: Efficacy Study of Subcutaneous Methyl B12 in Children with Autism: NCT01039792 ( clinicaltrials.gov1 ).

Building an evidence-informed service array: Considering evidence-based programs as well as their practice elements.

OBJECTIVE: This study empirically examined options for building an evidence-informed service array, comparing strategies to maximize the application of evidence-based treatment literature in a clinical service system. The overall goal was to determine the smallest set of treatments that could serve the largest percentage of clients. Solutions to this problem differ depending on how one defines "treatment." METHOD: Treatments were conceptualized as (a) programs (integrated treatments produced by specific research laboratories or investigators), and (b) collections of their constituent common procedures, referred to as practice elements. Programs listed by 2 separate government-sanctioned registries were selected to illustrate the effects of "program" conceptualizations, and all available clinical trials testing the programs were analyzed. Practice elements were identified from these same studies and from studies of other treatments that met a standard of evidence but had not been organized into programs on these lists. Relevance mapping methodology was used to identify optimal sets of programs and practice elements. RESULTS: Among a large, diverse clinical population, results identified 11%-22% of youths for whom practice elements provide an evidence-informed treatment option whereas no programs meeting the standard of evidence were available on the registries. Results for the practice elements were able to be matched by a hybrid combination: "best" programs, which were then extended by practice elements. CONCLUSIONS: These results demonstrated that there are multiple ways to conceptualize treatments when planning a service array, and these options have significant implications regarding who can be served by treatments supported by evidence.

Fit of evidence-based treatment components to youths served by wraparound process: a relevance mapping analysis.

This study investigated whether and which evidence-based treatment (EBT) components might generalize to youths served by the wraparound process. To examine these questions, the study used relevance mapping, an empirical methodology that compares youths in a given clinical population with participants in published randomized trials to determine who may be "coverable" by EBTs and which treatments may collectively be most applicable. In a large diverse clinical sample, youths receiving wraparound services (n = 828) were compared with youths receiving other services (n = 3,104) regarding (a) demographic and clinical profiles, (b) "coverability" by any EBTs, and (c) specific practices from those EBTs that most efficiently applied to each group. Participants in studies of EBTs matched the demographic and clinical characteristics of nearly as many youths receiving wraparound (58-59%) as those receiving non-wraparound services (61-64%). Moreover, the best-fitting solutions of relevant sets of practices were highly similar across groups. These results provide the first large-scale empirical characterization of fit between EBTs and youths receiving wraparound and suggest that these youths are well suited to benefit from clinical strategies commonly used in EBTs.

The demand side: uses of research in child and adolescent mental health services.

This special issue on child and adolescent mental health contains a thoughtful set of papers that address many of the challenges in bridging research and practice. These articles, however, focus predominantly on the supply side of producing research for use by a range of audiences, including practitioners, administrators and policymakers. This commentary emphasizes the importance of attending to, and better understanding, the demand side with regard to how research evidence is evaluated, understood,and utilized. Drawing from work underway at the William T. Grant Foundation, the authors argue for the need to understand three broad topics: user settings and perspectives, political, economic and social contexts, and the various uses of research. Furthermore, understanding the use of research evidence, or the demand side, is itself atopic for empirical investigation. The authors conclude that, when it comes to supplying evidence, don't forget the demand side.

If it walks like a duck and quacks like a duck then must it be a rabbit? Programs, systems and a cumulative science of children's mental health services.

The system of care approach as a strategy for serving children and adolescents with serious emotional disturbance (SED) is by any measure a success with one exception: there is controversy regarding the scientific evidence documenting that the services provided through systems of care improve the symptomatic and functional outcomes of the youth and their families served when compared to the services provided through more traditional service systems. This paper traces this essential problem to challenges in the definitions of systems of care, particularly the level at which systems of care are conceived to exist and the impact of these challenges on the collection of relevant and meaningful data that could otherwise create a cumulative science regarding systemic interventions for youth with SED. In many regards, systems of care are often viewed in the context of programs of care that are predominantly evaluated within program evaluation rather than system evaluation perspectives. This article elucidates the problems created by the varying definitions of systems of care for the development of a cumulative practice and policy relevant research base pertaining to children and adolescents with serious emotional disturbance. Alternative strategies for future research are discussed in the context of alternative definitions of the system of care concept.

Quality of publicly-funded outpatient specialty mental health care for common childhood psychiatric disorders in California.

OBJECTIVE: To describe the documented adherence to quality indicators for the outpatient care of attention-deficit/hyperactivity disorder, conduct disorder, and major depression for children in public mental health clinics and to explore how adherence varies by child and clinic characteristics. METHOD: A statewide, longitudinal cohort study of 813 children ages 6.0-16.9 years with at least 3 months of outpatient care, drawn from 4,958 patients in 62 mental health clinics in California from August 1, 1998, through May 31, 1999. The main outcome was documented adherence to quality indicators based on scientific evidence and clinical judgment, assessed by explicit medical record review. RESULTS: Relatively high adherence was recorded for clinical assessment (78%-95%), but documented adherence to quality indicators related to service linkage, parental involvement, use of evidence-based psychosocial treatment, and patient protection were moderate to poor (74.1%-8.0%). For children prescribed psychotropic medication, 28.3% of the records documented monitoring of at least one clinically indicated vital sign or laboratory study. Documented adherence to quality indicators varied little by child demographics or clinic factors. CONCLUSION: Efforts to improve care should be directed broadly across clinics, with documentation of safe practices, particularly for children prescribed psychotropic medication, being of highest priority.

Economic antecedents of foster care.

Individual and ecological research suggests that rising unemployment may affect the incidence of violence through two countervailing mechanisms suggested by frustration-aggression theory. The first, or provocation effect, assumes increased violence among persons who feel anger because they believe their job loss was arbitrary. The second, or inhibition effect, posits less violence among employed persons who attempt to reduce their chances of job loss by curtailing behavior objectionable to employers. The literature also reports that these mechanisms affect victimization measured as foster care sought by the state for abused children. The foster care finding, although consistent with theory and important for basic as well as applied reasons, arises from methods that cannot rule out several rival hypotheses. We revisit this research and apply improved methods to test the reported association in Los Angeles and San Francisco counties. We find that, as implied by the provocation and inhibition mechanisms, differences in monthly prevalence of foster care placements increase with modest increases in unemployment but decline when unemployment becomes much higher than usual levels.

Assessing the effectiveness of care for youth with severe emotional disturbances: is there agreement between popular outcome measures?

Limited information exists regarding how some popular measures for assessing the effectiveness of services to children with severe emotional disturbance interrelate when used as part of ongoing outcome accountability systems. This article examines the interrelationships--at intake and over time--between the Child Behavior Checklist (CBCL), the Youth Self Report (YSR), the Child and Adolescent Functional Assessment Scale (CAFAS), and Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM-IV) clinical diagnoses across six California care systems. At intake, there were mild to moderate relationships between the clinical diagnosis, the CAFAS, the CBCL, and the YSR. These relationships were not as strong as those found in other studies conducted in more controlled research environments. There was limited agreement among the CAFAS, the CBCL, and the YSR regarding the outcomes of the youths served. These findings raise questions regarding translating measures from research settings to clinical environments and reconciling differences between outcome measures.