Implementation of the Wolverine Mental Health Program, Part 2: Implementation Phase.

To enhance mental health care for youth in a midwestern residential treatment facility, Wolverine Human Services partnered with the Beck Institute (an intermediary) and an implementation research team to implement cognitive-behavioral therapy (CBT). CBT has strong evidence supporting effectiveness for treating youth internalizing and externalizing problems, but it is a complex psychosocial intervention that demands a thoughtful implementation approach. This study outlines the implementation phase (2.5 years) of a 5-year collaborative effort. The implementation phase focused on (a) adapting CBT to fit the complex youth needs and the roles of the multidisciplinary team members resulting in a new comprehensive and coordinated care model, and (b) the strategies utilized to support its competent integration by all team members. Six blended implementation strategies were deployed in this phase: forging implementation teams, installing progress monitoring, adapting CBT, training, providing supervision and consultation, and training the trainers. A components-based approach to CBT yielded six core skills: active listening, problem solving, mood monitoring and intervention mapping, activity scheduling, distress tolerance, and cognitive restructuring. By the end of this phase, all staff had robust exposure to and experience with the adapted form of CBT. The work of our academic-community partnership has both research and clinical implications, with respect to integrating an adapted version of CBT for residential environments (CBT-RE).

Implementation of the Wolverine Mental Health Program, Part 3: Sustainment Phase.

Sustaining the implementation of an evidence-based practice (EBP) is the ultimate goal of often years of significant personnel and financial investment. Some conceptualize sustainment as a distinct phase following an active implementation period where the contextual factors, processes, and supports are bolstered to ensure continued EBP delivery. This study provides an overview of the sustainment strategies deployed to embed cognitive-behavioral therapy (CBT) in a Midwestern residential treatment facility serving youth with complex mental health needs. Seven key strategies and their outcomes are described: use of CBT teams, new hire orientation plans, monthly campaigns, change in job descriptions and performance evaluations, development of a behavioral reinforcement system for youth, and a pathway to CBT certification. This study provides a window into how one might sustain an EBP by addressing barriers unique to this phase of work.

Implementation of the Wolverine Mental Health Program, Part 1: Adoption Phase.

Residential treatment facilities (RTFs) are a first-line treatment option for juvenile justice-involved youth. However, RTFs rarely offer evidence-based interventions for youth with internalizing or externalizing mental health problems. Wolverine Human Services (WHS) is one of the first RTFs in the nation to implement cognitive-behavioral therapy (CBT) to enhance mental health care for their youth. This study outlines the preimplementation phase of a 5-year collaborative CBT implementation effort among WHS, the Beck Institute, and an implementation science research team. The preimplementation phase included a needs assessment across two sites of WHS to identify and prioritize barriers to CBT implementation. Of the 76 unique barriers, 23 were prioritized as important and feasible to address. Implementation teams, consisting of clinician and staff champions and opinion leaders, worked across 8 months to deploy 10 strategies from a collaboratively designed blueprint. Upon reevaluation of the needs assessment domains, all prioritized barriers to CBT implementation were removed and WHS's readiness for CBT implementation was enhanced. This study serves as a model of a preimplementation process that can be employed to enhance the potential for successful evidence-based practice implementation in youth RTFs.

Development of a Brief Group CBT Intervention to Reduce COVID-19 Related Distress Among School-Age Youth.

School-aged youth have been significantly impacted by the COVID-19 pandemic. The effects of the pandemic will likely have long-standing effects on the well-being of youth, and access to mental health care is even more critical during this time. For the past 5 years, TRAILS (Transforming Research into Action to Improve the Lives of Students) has been working throughout the state to increase utilization of evidence-based mental health practices among K-12 school mental health professionals (SMHPs). By leveraging SMHPs who are widely accessible to students, TRAILS seeks to improve youth access to effective mental health care and reduce current mental health inequities. In March 2020, TRAILS responded to the COVID-19 pandemic by developing a group manual designed to be delivered virtually by SMHPs to help students develop effective coping skills to mitigate the impact of COVID-19. TRAILS focuses on promoting use of CBT and mindfulness, as these skills are ideally suited for school-based delivery, and thus the new manual, Coping with COVID-19 (CC-19), was grounded in these modalities. This article will describe the design, development, and deployment of the CC-19 program to address the mental health needs of students in the context of the pandemic. Early acceptability and penetration data will also be discussed.

A placebo prognostic index (PI) as a moderator of outcomes in the treatment of adolescent depression: Could it inform risk-stratification in treatment with cognitive-behavioral therapy, fluoxetine, or their combination?

Introduction: Researchers have proposed that predicting who is a likely placebo responder may help guide treatment allocations to treatment regimens that differ in intensity. Methods: We used data from the Treatment of Adolescent Depression Study (TADS) in which adolescents (n = 439) were randomized 1:1:1:1 to placebo, cognitive-behavioral therapy (CBT), medications (MEDs), or their combination (COMB). We developed a prognostic index (PI) in the placebo group to predict self-reported (RADS) and observer-rated (CDRS) depression outcomes using elastic net regularization. We explored whether the PIs moderated outcomes in the treatment conditions. Results: PI-CDRS was predicted by multiple variables but it did not moderate outcomes. PI-RADS was predicted by baseline severity, age, sleep problems, expectations, maternal depression, and the action stage of change. It moderated outcomes such that there were treatment differences for less placebo-responsive patients. For participants prone to placebo response, type of treatment had no statistically significant impact on outcomes. Baseline depression severity accounted for this effect: treatment differences were small and non-significant for patients with milder depression but larger in more severely depressed patients. Discussion: Future work should investigate whether multiple variable explain outcomes beyond severity as well as complex interactions between severity and other variables.

Ready or Not? Transitions of Depressed Adolescents During Acute Phase of Treatment.

Readiness to change has been identified as a predictor, moderator, and mediator of treatment. Individuals may start treatment in one stage and either stay, regress, or progress across stages, but there is little research exploring these transitions within mental health treatment. The present study addressed two aims: characterize the prevalence of stage membership and transitions, and explore predictors of stage membership and transitions. A Treatment for Adolescents with Depression Study sub-sample was used and participants (n = 383) ranged in age from 12 to 17, with a primary diagnosis of Major Depressive Disorder. The 18-item self-report Stages of Change Questionnaire was administered at baseline and week 6 of treatment. A latent transition analysis determined stage membership and transitions. Most adolescents initiated treatment in precontemplation or contemplation, and hopelessness predicted stage membership and stage transitions. This study revealed that readiness to change and hopelessness are related within the first few weeks of treatment, which may have implications for depressed adolescent's ability to benefit from care.

Can Cognitive-Behavioral Therapy Be Optimized With Parent Psychoeducation? A Randomized Effectiveness Trial of Adolescents With Major Depression in Puerto Rico.

This is a longitudinal randomized control trial on the impact of adding a parent psychoeducation intervention (TEPSI) as part of cognitive-behavioral therapy (CBT) for adolescents with Major Depressive Disorder (MDD) in a Puerto Rican sample. We tested the efficacy of adding 8 group sessions of TEPSI to 12 sessions of individual CBT on reducing depressive symptoms, MDD diagnosis, and improving family functioning. Participants (n = 121) were randomized to individual CBT with or without TEPSI. No main group effects were found for most patient domains including depression symptoms, as well as presence of adolescent's MDD diagnosis at posttreatment. Results did show a main effect of CBT over time for depression symptoms, suicide ideation, family criticism, and the presence of MDD diagnosis decreasing from pre- to postintervention. A year post treatment, almost 70% of adolescents in both conditions (CBT and CBT + TEPSI) remained in remission. A main effect was obtained for treatment in the adolescent's perception of familism and family emotional involvement. The primary hypothesis that family psychoeducation would optimize CBT for depression in adolescents was not supported. Both conditions yielded similar clinical end points. The culturally adapted CBT was found effective with Latino/a adolescents showing clinically significant improvements from pretreatment to posttreatment and remained stable at a 1-year follow-up. Regarding family outcomes, adolescents in CBT + TEPSI remained stable from pretreatment to posttreatment on family emotional involvement, while adolescents in CBT-alone showed an increase. The implication of these findings is discussed.

Este es un ensayo clínico longitudinal aleatorizado y controlado sobre el efecto de agregar una intervención psicoeducativa para los padres (TEPSI, en inglés) como parte de la terapia cognitivo-conductual (TCC) para adolescentes con trastorno depresivo mayor (TDM) en una muestra puertorriqueña. Evaluamos la eficacia de agregar 8 sesiones grupales de TEPSI a 12 sesiones de TCC individual en la reducción de síntomas depresivos, en el diagnóstico de TDM y en la mejora del funcionamiento familiar. Los participantes (n = 121) fueron distribuidos al azar a la TCC individual con o sin TEPSI. No se encontraron efectos grupales principales en la mayoría de las áreas de los pacientes, como en los síntomas de depresión ni en la presencia de un diagnóstico de TDM en los adolescentes después del tratamiento. Los resultados sí demostraron un efecto principal de la TCC con el tiempo para los síntomas de depresión, las ideas suicidas, la crítica familiar y la presencia de un diagnóstico de TDM que disminuye desde antes hasta después de la intervención. Un año después del final del tratamiento, casi el 70 % de los adolescentes en ambas condiciones (TCC y TCC + TEPSI) se mantuvo en remisión. Se obtuvo un efecto principal del tratamiento en la percepción de los adolescentes del familismo y la implicación emocional familiar. No se respaldó la hipótesis principal de que la psicoeducación familiar optimizaría la TCC para la depresión en los adolescentes. Ambas condiciones dieron variables clínicas similares. Se descubrió que la TCC culturalmente adaptada fue eficaz con los adolescentes latinos, ya que demostró mejoras clínicas considerables desde antes del tratamiento hasta después del tratamiento y permaneció estable un año después al momento del seguimiento. Con respecto a los resultados familiares, los adolescentes de la TCC + TEPSI se mantuvieron estables desde antes del tratamiento hasta después del tratamiento en la implicación emocional familiar, mientras que los adolescentes de la TCC sola demostraron un aumento. Se debaten las implicancias de estos resultados.

Number and Type of Meals consumed by Children in a Subset of Schools in San Juan, Puerto Rico.

OBJECTIVE: Eating patterns of children have been investigated in the U.S. and have been found to be changeable over extended time periods. Trends can be correlated to changes in the same periods for determinants of overall health such as body mass index (BMI). In Puerto Rico, there have been no such studies so similar correlations cannot be done. Herein, we present baseline information on the number and types of eating occasions in a convenience sample of children from the area of San Juan so that future changes in patterns can be monitored over time. METHODS: Multiple 24 hour recall questionnaires were administered to school children at 3 different grade levels. Number of eating occasions and type of meal (breakfast, lunch, dinner and snacks) were quantified. Factors considered for analysis were age, gender and BMI of the children, participation in the School Lunch Program (SLP) and if meals were eaten on a weekday or weekend day. RESULTS: Approximately 40% of children were categorized as overweight. There was a trend toward fewer eating occasions in older vs. younger children and fewer eating occasions on weekend days vs. weekdays. Lunch and dinner were consumed more frequently than breakfast and participants in the SLP had more eating occasions than non-participants. CONCLUSION: The number of eating occasions in Puerto Rican youth is maintained at about 5 for weekdays and about 4.5 per day for weekend days with a trend toward fewer meals as a function of increasing age. This data can be used as baseline information in future studies that wish to correlate changes in dietary patterns with health.

Outcomes of student trainee-delivered cognitive-behavioral therapy (CBT) on internalizing symptoms, CBT skills, and life satisfaction.

Increased quality of life (QoL) is rated by patients as a primary factor in determining recovery from psychopathology. Cognitive-behavioral therapies (CBTs) are the most well-researched psychotherapies for internalizing disorders and appear effective at reducing symptoms even when delivered by trainees. Existing research suggests that the effects of CBTs on QoL are more modest than their effects on symptoms. However, little is known about the effects of trainee-delivered CBT on life satisfaction, a subjective measure of QoL. We analyzed data from 93 clients treated by students (n=23) in a graduate-level training clinic using an intent-to-treat approach, completers case analyses, and random forest imputation. Across methods of handling missing data, improvements in anxiety, depression, and CBT skills were more marked than improvements in QoL. Exploratory analyses suggested baseline life satisfaction was the strongest predictor of end-of-treatment life satisfaction. Future research should explore alternatives to "standard" CBT for clients with low life satisfaction.

Developing a statewide network of coaches to support youth access to evidence-based practices.

Background: A national shortage of mental health providers for youth exists in the United States. Implementation support for mental health services in schools, where students are most likely to access care, can help to fill these gaps. Coaching consists of in vivo modeling and support during service delivery and is effective in supporting the implementation of evidence-based practices (EBPs). This implementation report describes the recruitment and training of community providers to become coaches as a part of a modified train-the-trainer model of implementation support. Method: An EBP implementation program, Transforming Research into Action to Improve the Lives of Students (TRAILS), trained community providers in Michigan to increase knowledge of cognitive behavioral therapy (CBT) and position them as coaches in schools. The development of the coach network involved five stages prior to the initiation of a randomized controlled trial: (1) recruitment, (2) a one-day clinical training, (3) 12 weeks of individualized consultation, (4) evaluation, and (5) training in the coaching protocol. Results: A total of 347 individuals attended an initial training, and 187 were paired with a consultant. Eighty-six clinicians from 47 of Michigan's 83 counties successfully became coaches by completing all required elements of training. Coaches showed significant improvements in the use and knowledge of CBT across consultation. Conclusion: Statewide networks of trained mental health professionals can address gaps in mental healthcare for youth. This article demonstrates one strategy for strengthening and leveraging community expertise to support the implementation of EPBs in schools. Plain Language Summary: Although youth face many barriers in accessing effective mental health care, schools are one setting where they can more easily receive treatment. Research shows that training and supports are needed for school mental health professionals to provide effective care. Coaching, which involves in vivo support for school mental health professionals, is one helpful strategy. We describe the process of recruiting and training community clinicians to become coaches. The Transforming Research into Action to Improve the Lives of Students (TRAILS) program successfully recruited and trained a network of 86 community clinicians to become coaches. Clinicians attended two day-long trainings and participated in 12 weeks of personalized consultation. Clients to whom these clinicians provided CBT showed significant symptom improvement. Clinicians also reported that they increased their knowledge and use of core CBT strategies, including psychoeducation, exposure, and behavioral activation. Community mental health professionals who are trained as coaches can address gaps in access to care for youth. We demonstrate one strategy for strengthening and leveraging clinicians' knowledge of CBT to support the school-based implementation of CBT.

Mental health needs in a large urban school district: Findings from a web-based survey.

OBJECTIVE: To explore the mental health needs of students, and the professional development and support needs of teachers and school health professionals, as a way to foster community engagement and help set priorities for a comprehensive school mental health system in the Detroit Public Schools Community District (DPSCD). SETTING: The study team surveyed all DPSCD staff in June 2019 and all students in grades 8-12 between October and December 2019. STUDY DESIGN: A descriptive study based on anonymous, web-based surveys focused on student trauma exposure and mental health symptoms, student mental health resource utilization, staff burnout, and professional development needs. DATA COLLECTION: All students (grades 8-12) and district staff were eligible to participate; the student survey was made available in six languages. Parents/guardians could opt children out; schools could exclude children unable to complete the survey independently. Student surveys were administered in school; staff surveys were sent via email. PRINCIPAL FINDINGS: Thirty-four percent of DPSCD students reported moderate/severe depression symptoms; 22% had seriously considered suicide in the past year. Rates exceed national averages; 37% of students with severe depression and 34% of those with suicidal ideation had not accessed mental health supports. Staff indicated high levels of burnout and substantial interest in learning about self-care strategies or coping with vicarious trauma. Over 75% of teachers and school mental health professionals expressed interest in learning about best practices for supporting students impacted by trauma or mental illness. CONCLUSIONS: A large number of DPSCD students are experiencing symptoms of depression and anxiety, and many students who need care are not accessing it. Addressing the mental health needs of students is a high priority for staff, but they need more training and support, as well as support for their own vicarious trauma and high levels of burnout.

In Search of Reliability: Expert-Informed Training Methods for Conducting Observational Coding of Cognitive Behavioral Therapy Fidelity.

BACKGROUND: Observational coding is the gold standard for measuring treatment fidelity; however, the intensive training needed for reliable and valid measurement has not been carefully scrutinized. A systematic review concluded there is a lack of information in published studies on how to approach training raters, and the available content suggests widely variable approaches are taken across research teams. The quality and comparability of the data produced from these treatment fidelity measures is undermined by heterogeneous training approaches occurring both within and between coding teams. No guidance for training teams to do observational coding for fidelity is currently available. The aims of the current study were to: (a) characterize expert-informed processes for observational coding regarding training, coding, and achieving reliability, and (b) generate expert recommendations for training and conducting observational coding. METHOD: A semi-structured interview was used to explore international CBT expert's (N = 11) perspectives and experiences regarding observational coding training processes. A qualitative content analysis approach was used to analyze the data. RESULTS: Experts in the study provided information about their training, coding, and reliability processes. CONCLUSION: Results from this study informed recommendations on how to: (a) introduce scale items, (b) anchor ratings, and (c) drift prevention.

The Cognitive Behavioral Therapy Competence Scale (CCS): initial development and validation.

Background: Nearly one-third of youth are affected by a mental health disorder, and the majority do not receive adequate care. To improve clinical outcomes among youth, efforts have been made to train providers in evidence-based mental health practices, such as cognitive behavioral therapy (CBT). Such efforts call for valid assessment measures that can inform and evaluate training activities. Aims: This study presents the development and validation of the CBT Competence Scale (CCS), a brief self-report measure to assess provider competence for CBT delivery. Method: Participants were 387 school mental health professionals (SMHPs) working with students in Michigan, USA. Initial items (n=59) were developed to evaluate competence in delivering common elements of CBT, with competence conceptualized as covering domains of knowledge, perception, and use of CBT techniques. CCS validation proceeded in three steps: using item response theory to select the most important items for assessing knowledge, evaluating the factor structure using exploratory and then confirmatory factor analyses, and examining reliability and validity of the resultant measure. Results: The validated CCS measure consists of four dimensions of CBT competence across 33 items: Non-behavioral skills, Behavioral skills, Perceptions, and Knowledge. The CCS demonstrated excellent internal consistency and good construct-based validity. Conclusions: The CCS holds promise as a valid, informative measure of CBT competence appropriate for the school setting, with potential for application in other environments such as mental health clinics.

Double trouble: Do symptom severity and duration interact to predicting treatment outcomes in adolescent depression?

Studies suggest that depression severity and duration interact to predict outcomes in depression treatment. To our knowledge, no study has explored this question in a sample with a placebo control, two therapies, and their combination nor with adolescents. We used data from the Treatment of Adolescent Depression Study (N = 439), in which adolescent were randomized to placebo (PBO), cognitive-behavioral therapy (CBT), antidepressants medications (MEDs), or their combination (COMB). We explore the interaction between depression severity, chronicity, and treatments (vs. placebo) in predicting outcomes. There was interaction between severity and chronicity when comparing COMB and CBT with PBO, but not MEDs. In non-chronic depression, the effects of CBT were inversely related to severity to the point that CBT appeared iatrogenic with more severe depression. In chronic depression, the effects of CBT did not vary by severity, but the relative effects of COMB grew, being smallest in milder, more dysthymic-like depression, and largest in chronic-severe depression. These findings support calls to classify depression by severity and chronicity as well efforts to risk stratify patients to different intensity of care according to these variables.

Radial Head Ingrowth Anatomic Implant Versus Smooth Stem Monoblock Implant in Acute Terrible Triad Injury: A Prospective Comparative Study.

OBJECTIVE: This study aimed to compare clinical outcomes and radiographic findings between patients who received 2 different implants (smooth-stemmed modular implant or an anatomic press-fit implant) on patients with acute terrible triad injuries. DESIGN: Prospective cohort. SETTING: Level II Trauma center, University hospital. PATIENTS/PARTICIPANTS: Thirty-four patients with an isolated terrible triad injury were divided into 2 study groups (n = 17 each) with different sets of radial head implants and followed for 2 years. A total of 14 patients in each group (n = 28) completed the study. INTERVENTION: Group 1 received a smooth-stemmed round modular monopolar implant. Group 2 received an in-growth modular monopolar press-fit anatomic implant. MAIN OUTCOME MEASUREMENTS: Clinical outcomes were evaluated using the Visual Analog Scale, Mayo Index, and Disabilities of the Arm, Shoulder, and Hand (DASH) survey. Radiographs were evaluated for ectopic bone formation and loosening. RESULTS: No difference in clinical outcome when comparing range of motion and functionally scores between groups. Ectopic bone formation occurred equally with implants. Bone formation at the proximal radius under the implant occurred more in group 1 (85.7%), (P = 0.046). Five press-fit stems had radiolucent lines at 2-year follow-up. Two were removed because of symptomatic loosening. CONCLUSIONS: Short-term outcomes for both implants showed to be equally effective treatment options. The in vitro biomechanical advantages of anatomic implants do not translate into short-term improved outcomes. Symptomatic aseptic loosening in anatomic implants is common. Bone formation at the proximal radial neck was observed more with smooth-stemmed implants; further studies should assess this findings and clinical implication. LEVEL OF EVIDENCE: Therapeutic Level II. See Instructions for Authors for a complete description of levels of evidence.