An Integrated Care Pathway for depression in adolescents: protocol for a Type 1 Hybrid Effectiveness-implementation, Non-randomized, Cluster Controlled Trial.

INTRODUCTION: Our group developed an Integrated Care Pathway to facilitate the delivery of evidence-based care for adolescents experiencing depression called CARIBOU-2 (Care for Adolescents who Receive Information 'Bout OUtcomes, 2nd iteration). The core pathway components are assessment, psychoeducation, psychotherapy options, medication options, caregiver support, measurement-based care team reviews and graduation. We aim to test the clinical and implementation effectiveness of the CARIBOU-2 pathway relative to treatment-as-usual (TAU) in community mental health settings. METHODS AND ANALYSIS: We will use a Type 1 Hybrid Effectiveness-Implementation, Non-randomized Cluster Controlled Trial Design. Primary participants will be adolescents (planned n = 300, aged 13-18 years) with depressive symptoms, presenting to one of six community mental health agencies. All sites will begin in the TAU condition and transition to the CARIBOU-2 intervention after enrolling 25 adolescents. The primary clinical outcome is the rate of change of depressive symptoms from baseline to the 24-week endpoint using the Childhood Depression Rating Scale-Revised (CDRS-R). Generalized mixed effects modelling will be conducted to compare this outcome between intervention types. Our primary hypothesis is that there will be a greater rate of reduction in depressive symptoms in the group receiving the CARIBOU-2 intervention relative to TAU over 24 weeks as per the CDRS-R. Implementation outcomes will also be examined, including clinician fidelity to the pathway and its components, and cost-effectiveness. ETHICS AND DISSEMINATION: Research ethics board approvals have been obtained. Should our results support our hypotheses, systematic implementation of the CARIBOU-2 intervention in other community mental health agencies would be indicated.

The Longitudinal Youth in Transition Study (LYiTS) Cohort Profile: Exploration by Hospital- Versus Community-Based Mental Health Services.

OBJECTIVES: Youth face numerous challenges in receiving coordinated and continuous mental health services, particularly as they reach the age of transition from child and adolescent mental health services (CAMHS) to adult mental health services (AMHS). The Longitudinal Youth in Transition Study (LYiTS) follows youth prospectively as they cross this transition boundary to better understand their transition pathways and resulting symptoms and health service use outcomes. The current paper presents the baseline profile description for the LYiTS cohort and additionally examines differences in symptoms and functioning and health service utilization between youth receiving services at hospital- versus community-based CAMHS. METHODS: A cross-sectional design was used. A sample of 237 16-18-year-old youth recruited from outpatient CAMHS at two hospitals and two community sites completed self-report measures at their first of four annual assessments. A latent profile analysis was conducted to identify symptomology profiles, and youth were compared on symptoms and health service use between hospital- and community-based sites. RESULTS: Four distinct symptomology profiles were identified (subclinical, moderate internalizing, moderate externalizing, and high symptomology). Symptom profiles and functioning levels reported by youth were no different across both types of organization, although there were differences detected in health service utilization, such as type of provider seen and use of medications. CONCLUSIONS: These findings suggest that there is little difference in symptomology between youth accessing hospital versus community-based CAMHS. With growing interest in understanding the effectiveness and cost-effectiveness of different models of mental health care, these findings provide a new understanding of the clinical and service use profiles of transition-aged youth that will be explored further as this cohort is followed across the CAMHS to AMHS transition boundary.

Prioritizing core components of successful transitions from child to adult mental health care: a national Delphi survey with youth, caregivers, and health professionals.

Youth accessing mental health care often experience a disruption in care as they attempt to transition between child and adolescent mental health services (CAMHS) and adult mental health services (AMHS). Few studies have evaluated interventions seeking to improve the experience and outcomes of CAMHS-AMHS transitions, in part due to lack of consensus on what constitutes best practices in intervention success. As such, the aim of this study was to engage patients, caregivers, and clinicians to prioritize core components of successful CAMHS-AMHS transitions which can be used in the design or evaluation of transition interventions. As such, a Delphi study was conducted to determine core components of successful CAMHS-AMHS transitions. Guided by the principles of patient-oriented research, three balanced expert panels consisting of youth, caregivers, and clinicians ranked and provided feedback on the importance and feasibility of core components of CAMHS-AMHS transitions. Components endorsed as feasible or important with ≥ 70% agreement from any panel moved to the next round. As a result, a list of 26 core components of CAMHS-AMHS transitions has been refined which can be used in the design, implementation, or evaluation of interventions intended to improve transition experiences and outcomes for youth in mental health care. Youth and families were engaged in an expert advisory role throughout the research process, contributing their important perspectives to the design and implementation of this study, as well as interpretation of the findings.

Forks in the road: Definitions of response, remission, recovery, and other dichotomized outcomes in randomized controlled trials for adolescent depression. A scoping review.

BACKGROUND: Definitions of dichotomous outcome terms, such as "response," "remission," and "recovery" are central to the design, interpretation, and clinical application of randomized controlled trials of adolescent depression interventions. Accordingly, this scoping review was conducted to document how these terms have been defined and justified in clinical trials. METHOD: Bibliographic databases MEDLINE, Embase, APA PsycInfo, and CINAHL were searched from inception to February 2020 for randomized controlled trials evaluating treatments for adolescent depression. Ninety-eight trials were included for data extraction and analysis. RESULTS: Assessment of outcome measurement instruments, metric strategies, methods of aggregation, and measurement timing, yielded 53 unique outcome definitions of "response" across 45 trials that assessed response, 47 unique definitions of "remission" in 29 trials that assessed remission, and 19 unique definitions of "recovery" across 11 trials that assessed recovery. A minority of trials (N = 35) provided a rationale for dichotomous outcomes definitions, often by citing other studies that used a similar definition (N = 11). No rationale included input from youth or families with lived experience. CONCLUSION: Our review revealed that definitions of "response," "remission," "recovery," and related terms are highly variable, lack clear rationales, and are not informed by key stakeholder input. These limitations impair pooling of trial results and the incorporation of trial findings into pragmatic treatment decisions in clinical practice. Systematic approaches to establishing outcome definitions are needed to enhance the impact of trials examining adolescent depression treatment.

Identifying core components and indicators of successful transitions from child to adult mental health services: a scoping review.

The aim of this scoping review was to identify the core components of interventions that facilitate successful transition from child and adolescent mental health services to adult mental health services. In the absence of rigorous evaluations of transition program effectiveness for transitioning youth with mental health care needs, these core components can contribute to informed decisions about promising program and intervention strategies. This review examined data from 87 peer-reviewed and non-academic documents to determine the characteristics that support the transition process and to identify opportunities for system and program improvement. Data were extracted and synthesized using a descriptive analytic framework. A major finding of this review is a significant lack of measurable indicators in the academic and gray literature. This review did identify 26 core components organized within the framework of the six core elements of healthcare transitions. Policy makers, practitioners, and administrators can use the core components to guide decisions about transition program and intervention content. Confirmation of the impact of these core program components on youth outcomes awaits the conduct of rigorous randomized trials. Future research also needs to explicitly focus on the development of indicators to evaluate transition programs and interventions.

Research Review: Test-retest reliability of standardized diagnostic interviews to assess child and adolescent psychiatric disorders: a systematic review and meta-analysis.

BACKGROUND: A better understanding of factors contributing to the observed variability in estimates of test-retest reliability in published studies on standardized diagnostic interviews (SDI) is needed. The objectives of this systematic review and meta-analysis were to estimate the pooled test-retest reliability for parent and youth assessments of seven common disorders, and to examine sources of between-study heterogeneity in reliability. METHODS: Following a systematic review of the literature, multilevel random effects meta-analyses were used to analyse 202 reliability estimates (Cohen's kappa = Ò¡) from 31 eligible studies and 5,369 assessments of 3,344 children and youth. RESULTS: Pooled reliability was moderate at Ò¡ = .58 (CI 95% 0.53-0.63) and between-study heterogeneity was substantial (Q = 2,063 (df = 201), p < .001 and I2  = 79%). In subgroup analysis, reliability varied across informants for specific types of psychiatric disorder (Ò¡ = .53-.69 for parent vs. Ò¡ = .39-.68 for youth) with estimates significantly higher for parents on attention deficit hyperactivity disorder, oppositional defiant disorder and the broad groupings of externalizing and any disorder. Reliability was also significantly higher in studies with indicators of poor or fair study methodology quality (sample size <50, retest interval <7 days). CONCLUSIONS: Our findings raise important questions about the meaningfulness of published evidence on the test-retest reliability of SDIs and the usefulness of these tools in both clinical and research contexts. Potential remedies include the introduction of standardized study and reporting requirements for reliability studies, and exploration of other approaches to assessing and classifying child and adolescent psychiatric disorder.

Prevalence and Correlates of Youth Suicidal Ideation and Attempts: Evidence from the 2014 Ontario Child Health Study.

OBJECTIVES: To present the 12-month prevalence and correlates of suicidal ideation and attempts in a sample of youth in Ontario. METHODS: Data come from the 2014 Ontario Child Health Study, a provincially representative survey of families with children in Ontario. Youth aged 14 to 17 y ( n = 2,396) completed a computer-assisted, self-administered questionnaire in their home to assess the occurrence of suicidal ideation, suicidal attempts, and associated correlates, including non-suicidal self-injury, mental disorders, substance use, peer victimization and exposure to child maltreatment. Socio-demographic information was collected from the parent. Logistic regression models were used to identify correlates that distinguished between youth reporting: 1) no suicidal ideation or attempts, 2) suicidal ideation but no attempts, and 3) suicidal ideation and attempts. RESULTS: The 12-month prevalence of suicidal ideation and attempts was 8.1% and 4.3%, respectively. All clinical and behavioural correlates were significantly higher among youth reporting suicidal ideation or attempts, as compared with non-suicidal youth. In adjusted models, depression and non-suicidal self-injury were each independently associated with elevated odds of suicidal ideation (OR = 4.84 and 4.19, respectively) and suicidal attempt (OR = 7.84 and 22.72, respectively). Among youth who reported suicidal ideation, the only variable that differentiated youth who attempted suicide v. those who did not, in adjusted models, was non-suicidal self-injury (OR = 3.89). CONCLUSIONS: Suicidal ideation and attempts are common among youth in Ontario, often co-occurring with mental disorders and high-risk behaviours. These findings underscore the need for effective prevention and intervention strategies, particularly for youth depression and non-suicidal self-injury.

Emergency Department Presentations and Youth Suicide: A Case-Control Study.

OBJECTIVE: We estimate associations between emergency department (ED) diagnoses and suicide among youth to guide ED care. METHOD: This ED-based case-control study used data from the Office of the Chief Coroner and all EDs in Ontario, Canada. Cases ( n = 697 males and n = 327 females) were aged 10 to 25 years who died by suicide in Ontario between April 2003 and March 2014, with an ED contact in the year before their death. Same-aged ED-based controls were selected during this time frame. Crude and adjusted odds ratios (aORs) and 95% confidence intervals were calculated. RESULTS: Among youth diagnosed with a mental health problem at their most recent ED contact (41.9% cases, 5% controls), suicide was elevated among nonfatal self-inflicted: 'other' injuries, including hanging, strangulation, and suffocation in both sexes (aORs > 14); cut/pierce injuries in males (aOR > 5); poisonings in both sexes (aORs > 2.2); and mood and psychotic disorders in males (aORs > 1.7). Among those remaining, 'undetermined' injuries and poisonings in both sexes (aORs > 5), 'unintentional' poisonings in males (aOR = 2.1), and assault in both sexes (aORs > 1.8) were significant. At least half of cases had ED contact within 106 days. CONCLUSIONS: The results highlight the need for timely identification and treatment of mental health problems. Among those with an identified mental health problem, important targets for suicide prevention efforts are youth with self-harm and males with mood and psychotic disorders. Among others, youth with unintentional poisonings, undetermined events, and assaults should raise concern.

The 2014 Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) Part II: Psychometric Adequacy for Categorical Measurement of Selected DSM-5 Disorders.

OBJECTIVES: To compare the reliability and convergent validity of parent assessments from the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID-a structured diagnostic interview) and the Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) symptom checklist for classifying conduct disorder (CD), conduct disorder or oppositional defiant disorder (CD-ODD), attention-deficit hyperactivity disorder (ADHD), major depressive disorder (MDD), generalized anxiety disorder (GAD), and separation anxiety disorder (SAD) based on DSM-5 criteria. METHODS: Data came from 283 parent-youth dyads aged 9 to 18 years. Parents and youth completed the assessments separately on 2 different occasions 7 to 14 days apart. After converting the OCHS-EBS scale scores to binary disorder classifications, we compare test-retest reliability estimates and use structural equation modelling (SEM) to compare estimates of convergent validity for the same disorders assessed by each instrument. RESULTS: Average test-retest reliabilities based on κ were 0.71 (MINI-KID) and 0.67 (OCHS-EBS). The average ß coefficients for 3 latent measures comprising the following indicators-parent perceptions of youth mental health need and impairment, diagnosis of specific disorders based on health professional communications and youth taking prescribed medication, and youth classifications of disorder based on the MINI-KID-were 0.67 (MINI-KID) and 0.69 (OCHS-EBS). CONCLUSION: The OCHS-EBS and MINI-KID achieve comparable levels of reliability and convergent validity for classifying child psychiatric disorder. The flexibility, low cost, and minimal respondent burden of checklists for classifying disorder make them well suited for studying disorder in the general population and screening in clinical settings.

The 2014 Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) Part I: A Checklist for Dimensional Measurement of Selected DSM-5 Disorders.

OBJECTIVES: To describe the development and psychometric properties of the 2014 Ontario Child Health Study Emotional Behavioural Scales (OCHS-EBS) for dimensional measurement of 7 disorders based on criteria from the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). METHODS: Scale items were selected by agreement among 19 child psychologists and psychiatrists rating the correspondence between item descriptions and DSM-5 symptoms. Psychometric evaluation of the item properties and parent/caregiver and youth scales came from a general population study of 10,802 children and youth aged 4 to 17 years in 6537 families. Test-retest reliability data were collected from a subsample of 280 children and their caregivers who independently completed the OCHS-EBS checklist on 2 occasions 7 to 14 days apart. Structural equation modelling was used to assess internal and external convergent and discriminant validity-the latter tested against the Mini International Neuropsychiatric Interview for Children and Adolescents (MINI-KID). RESULTS: Confirmatory factor analyses exhibited adequate item fit to all scales. Except for conduct disorder and youth-assessed separation anxiety disorder, internal (Cronbach's α) and test-retest reliability (Pearson's r) for scale scores were 0.70 or above. Except for youth-assessed conduct disorder, the OCHS-EBS met criteria for internal and convergent and discriminant validity. Compared with the MINI-KID, the OCHS-EBS met criteria for external convergent and discriminant validity. CONCLUSIONS: The OCHS-EBS provide reliable and valid dimensional measurement of 7 DSM-5 disorders assessed by caregivers and youth in the general population. Part II describes use of the OCHS-EBS as a categorical (present/absent) measure of disorder.

Design and Delivery Features That May Improve the Use of Internet-Based Cognitive Behavioral Therapy for Children and Adolescents With Anxiety: A Realist Literature Synthesis With a Persuasive Systems Design Perspective.

BACKGROUND: Internet-based cognitive behavioral therapy (iCBT) is a persuasive system as its design combines therapeutic content, technological features, and interactions between the user and the program to reduce anxiety for children and adolescents. How iCBT is designed and delivered differs across programs. Although iCBT is considered an effective approach for treating child and adolescent anxiety, rates of program use (eg, module completion) are highly variable for reasons that are not clear. As the extent to which users complete a program can impact anxiety outcomes, understanding what iCBT design and delivery features improve program use is critical for optimizing treatment effects. OBJECTIVE: The objectives of this study were to use a realist synthesis approach to explore the design and delivery features of iCBT for children and adolescents with anxiety as described in the literature and to examine their relationship to program use outcomes. METHODS: A search of published and gray literature was conducted up to November 2017. Prespecified inclusion criteria identified research studies, study protocols, and program websites on iCBT for child and adolescent anxiety. Literature was critically appraised for relevance and methodological rigor. The persuasive systems design (PSD) model, a comprehensive framework for designing and evaluating persuasive systems, was used to guide data extraction. iCBT program features were grouped under 4 PSD categories-Primary task support, Dialogue support, System credibility support, and Social support. iCBT design (PSD Mechanisms) and delivery features (Context of use) were linked to program use (Outcomes) using meta-ethnographic methods; these relationships were described as Context-Mechanism-Outcome configurations. For our configurations, we identified key PSD features and delivery contexts that generated moderate-to-high program use based on moderate-to-high quality evidence found across multiple iCBT programs. RESULTS: A total of 44 documents detailing 10 iCBT programs were included. Seven iCBT programs had at least one document that scored high for relevance; most studies were of moderate-to-high methodological rigor. We developed 5 configurations that highlighted 8 PSD features (Tailoring, Personalization [Primary task supports]; Rewards, Reminders, Social role [Dialogue supports]; and Trustworthiness, Expertise, Authority [System credibility supports]) associated with moderate-to-high program use. Important features of delivery Context were adjunct support (a face-to-face, Web- or email-based communications component) and whether programs targeted the prevention or treatment of anxiety. Incorporating multiple PSD features may have additive or synergistic effects on program use. CONCLUSIONS: The Context-Mechanism-Outcome configurations we developed suggest that, when delivered with adjunct support, certain PSD features contribute to moderate-to-high use of iCBT prevention and treatment programs for children and adolescents with anxiety. Standardization of the definition and measurement of program use, formal testing of individual and combined PSD features, and use of real-world design and testing methods are important next steps to improving how we develop and deliver increasingly useful treatments to target users.

An appraisal of the trustworthiness of practice guidelines for depression and anxiety in children and youth.

OBJECTIVE: Little is known about the trustworthiness of clinical practice guidelines (PGs) relevant to child and youth depression or anxiety. To address this gap, we used systematic review methods to identify all available relevant PGs, quality appraise them, and make recommendations regarding which PGs are trustworthy and should be used by clinicians. METHODS: Prespecified inclusion criteria identified eligible PGs. Two independent trained reviewers applied the Appraisal of Guidelines for Research and Evaluation (AGREE II) tool. Using three AGREE II domain scores (stakeholder involvement, rigor of development [clinical validity/trustworthiness], and editorial independence), PG quality was designated as (1) minimum (≥50%) and (2) high (≥70%). RESULTS: Of 25 eligible PGs, five met minimum quality criteria (depression, n = 4; anxiety, n = 1); three out of five met high-quality criteria (depression, n = 2; anxiety, n = 1). Among the five minimum quality PGs, developers included government (n = 2), independent expert groups (n = 2), and other (n = 1). No PGs developed by specialty societies achieved minimum or high-quality ratings; eight of 25 PGs were up-to-date. CONCLUSIONS: Trustworthy PGs are available to support clinical decisions about depression and anxiety in children and youth, but are few in number. Many existing PGs (up to 80%) may not be clinically valid. Clinicians who implement the high-quality PGs identified here can increase the number of children and youth who receive effective interventions for depression and anxiety, minimize harm, and avoid wasted resources. Clinicians, service planners, youth, and their families should encourage PG developers to increase the pool of high-quality PGs using internationally recognized PG development standards.

Les soins médicaux de jeunes hommes et de jeunes femmes qui décèdent par suicide.

OBJECTIVE: Prior year medical care was compared among youth dying by suicide to their peers. Effect modification of these associations by age or place of residency (rural versus larger community sizes) was examined in a large, medically insured population. METHOD: This population-based case control study used data from the Office of the Chief Coroner in Ontario, Canada, linked to health care administrative data to examine associations between medical care for mental health or other reasons (versus no medical care) and suicide. Decedents ( n = 1203 males and n = 454 females) were youth (aged 10 to 25 years) who died by suicide in Ontario between April 2003 and March 2014, inclusive. Peers of the same ages were frequency matched to decedents on sex and place of residency. Logistic regression was used to calculate odds ratios and 95% confidence intervals and to test effect modification. RESULTS: Associations with mental health care were stronger in decedents than peers with a gradation of care (i.e., outpatient only, emergency department [ED], inpatient care) in both sexes. However, these associations were weaker among youth living in rural communities. Furthermore, older males (aged 18 to 25 years) were less likely than younger males (aged 10 to 17 years) to access the ED (ambulatory care only). This decrease was observed in rural and larger communities alongside no increase in medical care for other reasons. CONCLUSIONS: Geographical and age-related barriers to mental health care exist for youth who die by suicide. Preventive efforts can address these barriers, intervening early and integrating services, including the ED.

How do eHealth Programs for Adolescents With Depression Work? A Realist Review of Persuasive System Design Components in Internet-Based Psychological Therapies.

BACKGROUND: Major depressive disorders are common among adolescents and can impact all aspects of their daily life. Traditional therapies, cognitive behavioral therapy (CBT), and interpersonal psychotherapy (IPT) have been delivered face-to-face. However, Internet-based (online) delivery of these therapies is emerging as an option for adolescents. Internet-based CBT and IPT involve therapeutic content, interaction between the user and the system, and different technological features embedded into the online program (eg, multimedia). Studies of Internet-based CBT and IPT for adolescent depression differ on all three aspects, and variable, positive therapy effects have been reported. A better understanding of the treatment conditions that influence therapy outcomes is important to designing and evaluating these novel therapies. OBJECTIVE: Our aim was to examine the technological and program delivery features of Internet-based CBT and IPT for adolescent depression and to document their potential relation to treatment outcomes and program use. METHODS: We performed a realist synthesis. We started with an extensive search of published and gray literature. We included intervention studies that evaluated Internet-based CBT or IPT for adolescent depression. We included mixed-methods and qualitative studies, theoretical papers, and policy/implementation documents if they included a focus on how Internet-based psychological therapy is proposed to work for adolescents with depression/depressive symptoms. We used the Mixed-Methods Appraisal Tool to assess the methodological quality of studies. We used the Persuasive System Design (PSD) model as a framework for data extraction and analysis to examine how Internet-based CBT and IPT, as technology-based systems, influence the attitudes and behaviors of system users. PSD components described for the therapies were linked to reported outcomes using a cross-case comparison method and thematic synthesis. RESULTS: We identified 19 Internet-based CBT programs in 59 documents. Of those, 71% (42/59) were of moderate to high quality. The PSD features surface credibility (competent "look and feel"), dialogue support (online program + in-person support), liking and similarity (esthetics and content appeal to adolescent users), the reduction and tunneling of therapeutic content (reducing online content into simple tasks, guiding users), and use of self-monitoring were present in therapies that resulted in improved therapy engagement, satisfaction, and adherence, as well as symptom and functional impairments. CONCLUSIONS: When incorporated into Internet-based CBT for adolescent depression, PSD features may improve adolescent adherence, satisfaction, and depression-related outcomes. Testing of these features using hypothesis-driven dismantling approaches is recommended to advance our understanding of how these features contribute to therapy effectiveness.

Implementation of eMental Health care: viewpoints from key informants from organizations and agencies with eHealth mandates.

BACKGROUND: The use of technology such as computers, tablets, and smartphones to improve access to and the delivery of mental health care (eMental Health care) is growing worldwide. However, despite the rapidly expanding evidence base demonstrating the efficacy of eMental Health care, its implementation in clinical practice and health care systems remains fragmented. To date, no peer-reviewed, key-informant studies have reported on the perspectives of decision-makers concerned with whether and how to implement eMental Health care. METHODS: From September to November 2015, we conducted 31 interviews with key informants responsible for leadership, policy, research, and/ or information technology in organizations influential in the adoption of technology for eMental Health care. Deductive and inductive thematic analyses of transcripts were conducted using the Behavior Change Wheel as an organizing framework. Frequency and intensity effect sizes were calculated for emerging themes to further explore patterns within the data. RESULTS: Key informant responses (n = 31) representing 6 developed countries and multiple organizations showed consensus on common factors impacting implementation: individual and organizational capacities (e.g., computer literacy skills [patients and providers], knowledge gaps about cyber security, limited knowledge of available services); motivational drivers of technology-based care (e.g., extending care, data analytics); and opportunities for health systems to advance eMental Health care implementation (e.g., intersectoral research, rapid testing cycles, sustainable funding). Frequency effect sizes showed strong associations between implementation and credibility, knowledge, workflow, patient empowerment, electronic medical record (EMR) integration, sustained funding and intersectoral networks. Intensity effect sizes showed the highest concentration of statements (>10% of all comments) related to funding, credibility, knowledge gaps, and patient empowerment. CONCLUSION: This study provides previously unavailable information about key informant perspectives on eMental Health care implementation. The themes that emerged, namely the need to intensify intersectoral research, measure/monitor readiness to implement, define cost-utility benchmarks, raise awareness about available technologies, and test assumptions that 'proven' technologies will be easily integrated can inform the design and evaluation of eMental Health care implementation models.

Practitioner Review: On the trustworthiness of clinical practice guidelines - a systematic review of the quality of methods used to develop guidelines in child and youth mental health.

BACKGROUND: Numerous practice guidelines (PGs) relevant to child and youth mental health (CYMH) are available, but their quality is uncertain. We used systematic review methodology to identify the methods employed to develop PGs in CYMH and assess whether they align with international quality standards. METHODS: We used prespecified inclusion criteria to search for CYMH PGs (2009-2014) in journals of professional associations or websites of organizations who produce or house PGs. Eligible PGs and organization websites were screened to identify PG development methods. Two reviewers assessed the alignment of the PG development methods with PG quality criteria using the Appraisal of Guidelines for Research and Evaluation (AGREE II) domains and Institute of Medicine (IOM) standards. RESULTS: Five sets of eligible development methods were identified in 70 eligible PGs. Three sets adhered to all (National Institute for Health and Care Excellence; Scottish Intercollegiate Guidelines Network) or most (U.S. Preventive Services Task Force) AGREE II domains and IOM standards, and were used to develop 31.4% of PGs. The two remaining sets of development methods had important weaknesses (e.g. lack of mandatory rigorous systematic reviews, multidisciplinary development groups, or transparent conflict of interest methods) and were associated with 21.4% of PGs. No development methods could be identified in 40.0% of PGs; ineligible development methods were referenced in 7.1% of PGs. CONCLUSIONS: Up to 69% of available CYMH PGs may have been developed using methods that do not align with AGREE II quality criteria or IOM standards. The quality of available CYMH PGs needs to be assessed, and strategies designed to guide practitioners to high quality PGs and facilitate adherence by PG developers to international quality standards are needed.

PREVENTING CHILD AND ADOLESCENT ANXIETY DISORDERS: OVERVIEW OF SYSTEMATIC REVIEWS.

Overviews of systematic reviews (OSRs) provide rapid access to high quality, consolidated research evidence about prevention intervention options, supporting evidence-informed decision-making, and the identification of fruitful areas of new research. This OSR addressed three questions about prevention strategies for child and adolescent anxiety: (1) Does the intervention prevent anxiety diagnosis and/or reduce anxiety symptoms compared to passive controls? (2) Is the intervention equal to or more effective than active controls? (3) What is the evidence quality (EQ) for the intervention? Prespecified inclusion criteria identified systematic reviews and meta-analyses (2000-2014) with an AMSTAR quality score ≥ 3/5. EQ was rated using Oxford evidence levels EQ1 (highest) to EQ5 (lowest). Three reviews met inclusion criteria. One narrative systematic review concluded school-based interventions reduce anxiety symptoms. One meta-analysis pooled 65 randomized controlled trials (RCTs; any intervention) and reported a small, statistically significant reduction in anxiety symptoms and diagnosis incidence. Neither review provided pooled effect size estimates for specific intervention options defined by type (i.e., universal/selective/indicated), intervention content, or comparison group (i.e., passive/active control), thus precluding EQ ratings. One meta-analysis pooled trials of vigorous exercise and reported small, nonstatistically significant reductions in anxiety symptoms for comparisons against passive and active controls (EQ1). Better use of primary studies in meta-analyses, including program-specific pooled effect size estimates and network meta-analysis is needed to guide evidence-informed anxiety prevention program choices. RCTs of innovative community/primary care based interventions and web-based strategies can fill knowledge gaps.

A Youth Suicide Prevention Plan for Canada: A Systematic Review of Reviews.

OBJECTIVE: We conducted an expedited knowledge synthesis (EKS) to facilitate evidence-informed decision making concerning youth suicide prevention, specifically school-based strategies and nonschool-based interventions designed to prevent repeat attempts. METHODS: Systematic review of review methods were applied. Inclusion criteria were as follows: systematic review or meta-analysis; prevention in youth 0 to 24 years; peer-reviewed English literature. Review quality was determined with AMSTAR (a measurement tool to assess systematic reviews). Nominal group methods quantified consensus on recommendations derived from the findings. RESULTS: No included review addressing school-based prevention (n = 7) reported decreased suicide death rates based on randomized controlled trials (RCTs) or controlled cohort studies (CCSs), but reduced suicide attempts, suicidal ideation, and proxy measures of suicide risk were reported (based on RCTs and CCSs). Included reviews addressing prevention of repeat suicide attempts (n = 14) found the following: emergency department transition programs may reduce suicide deaths, hospitalizations, and treatment nonadherence (based on RCTs and CCSs); training primary care providers in depression treatment may reduce repeated attempts (based on one RCT); antidepressants may increase short-term suicide risk in some patients (based on RCTs and meta-analyses); this increase is offset by overall population-based reductions in suicide associated with antidepressant treatment of youth depression (based on observational studies); and prevention with psychosocial interventions requires further evaluation. No review addressed sex or gender differences systematically, Aboriginal youth as a special population, harm, or cost-effectiveness. Consensus on 6 recommendations ranged from 73% to 100%. CONCLUSIONS: Our EKS facilitates decision maker access to what is known about effective youth suicide prevention interventions. A national research-to-practice network that links researchers and decision makers is recommended to implement and evaluate promising interventions; to eliminate the use of ineffective or harmful interventions; and to clarify prevention intervention effects on death by suicide, suicide attempts, and suicidal ideation. Such a network could position Canada as a leader in youth suicide prevention.

Translating Cognitive Behavioral Therapy for Anxious Youth to Rural-Community Settings via Tele-Psychiatry.

This study aimed to determine the feasibility of translating cognitive behavioral therapy for anxious youth to rural-community settings via tele-psychiatry training. A 20-week group-supervision training program was delivered to ten different groups from different agencies within Northern Ontario. Each group consisted of four to nine clinicians with child therapy background not specific to CBT (n = 78, 51% social workers, 49% other mental health disciplines). Clinicians were each required to treat an anxious youth under supervision. Changes in clinician knowledge and youth internalizing symptoms were measured. Northern Ontario clinicians showed significant gains on a child CBT-related knowledge test (t (1, 52) = -4.6, p < .001). Although youth treated by these clinicians showed a significant decrease in anxiety symptoms, possible response bias and the lack of a comparison group mandate further studies before generalizing our findings. Nevertheless, training local therapists in anxiety-focused CBT for children via a group supervision based tele-psychiatry model appears to be a feasible and well-received approach to knowledge translation to rural settings.

Cognitive behavioral therapy age effects in child and adolescent anxiety: an individual patient data metaanalysis.

BACKGROUND: Investigations of age effects on youth anxiety outcomes in randomized trials (RCTs) of cognitive behavior therapy (CBT) have failed to yield a clear result due to inadequate statistical power and methodologic weaknesses. We conducted an individual patient data metaanalysis to address this gap. QUESTION: Does age moderate CBT effect size, measured by a clinically and statistically significant interaction between age and CBT exposure? METHODS: All English language RCTs of CBT for anxiety in 6-19 year olds were identified using systematic review methods. Investigators of eligible trials were invited to submit their individual patient data. The anxiety disorder interview schedule (ADIS) primary diagnosis severity score was the primary outcome. Age effects were investigated using multilevel modeling to account for study level data clustering and random effects. RESULTS: Data from 17 of 23 eligible trials were obtained (74%); 16 studies and 1,171 (78%) cases were available for the analysis. No interaction between age and CBT exposure was found in a model containing age, sex, ADIS baseline severity score, and comorbid depression diagnosis (power ≥ 80%). Sensitivity analyses, including modeling age as both a categorical and continuous variable, revealed this result was robust. CONCLUSIONS: Adolescents who receive CBT in efficacy research studies show benefits comparable to younger children. However, CBT protocol modifications routinely carried out by expert trial therapists may explain these findings. Adolescent CBT protocols are needed to facilitate the transportability of efficacy research effects to usual care settings where therapists may have less opportunity for CBT training and expertise development.