Improving measurement-based care implementation in adult ambulatory psychiatry: a virtual focus group interview with multidisciplinary healthcare professionals.

BACKGROUND: Measurement-Based Care (MBC) is an evidence-based practice shown to enhance patient care. Despite being efficacious, MBC is not commonly used in practice. While barriers and facilitators of MBC implementation have been described in the literature, the type of clinicians and populations studied vary widely, even within the same practice setting. The current study aims to improve MBC implementation in adult ambulatory psychiatry by conducting focus group interviews while utilizing a novel virtual brainwriting premortem method. METHODS: Semi-structured focus group interviews were conducted with clinicians (n = 18) and staff (n = 7) to identify their current attitudes, facilitators, and barriers of MBC implementation in their healthcare setting. Virtual video-conferencing software was used to conduct focus groups, and based on transcribed verbatin, emergent barriers/facilitators and four themes were identified. Mixed methods approach was utilized for this study. Specifically, qualitative data was aggregated and re-coded separately by three doctoral-level coders. Quantitative analyses were conducted from a follow-up questionnaire surveying clinician attitudes and satisfaction with MBC. RESULTS: The clinician and staff focus groups resulted in 291 and 91 unique codes, respectively. While clinicians identified a similar number of barriers (40.9%) and facilitators (44.3%), staff identified more barriers (67%) than facilitators (24.7%) for MBC. Four themes emerged from the analysis; (1) a description of current status/neutral opinion on MBC; (2) positive themes that include benefits of MBC, facilitators, enablers, or reasons on why they conduct MBC in their practice, (3) negative themes that include barriers or issues that hinder them from incorporating MBC into their practice, and (4) requests and suggestions for future MBC implementation. Both participant groups raised more negative themes highlighting critical challenges to MBC implementation than positive themes. The follow-up questionnaire regarding MBC attitudes showed the areas that clinicians emphasized the most and the least in their clinical practice. CONCLUSION: The virtual brainwriting premortem focus groups provided critical information on the shortcomings and strengths of MBC in adult ambulatory psychiatry. Our findings underscore implementation challenges in healthcare settings and provide insight for both research and clinical practice in mental health fields. The barriers and facilitators identified in this study can inform future training to increase sustainability and better integrate MBC with positive downstream outcomes in patient care.

Effects of COVID-19 on Patients in Adult Ambulatory Psychiatry: Using Patient-Rated Outcome Measures and Telemedicine.

Introduction: To examine the effects of coronavirus disease 2019 (COVID-19) on patients in an academic psychiatric ambulatory clinic, data from a measurement-based care (MBC) system were analyzed to evaluate impacts on psychiatric functioning in patients using telemedicine. Psychiatric functioning was evaluated for psychological distress (brief adjustment scale [BASE]-6), depression (patient health questionnaire [PHQ]-9), and anxiety (generalized anxiety disorder [GAD]-7), including initial alcohol (U.S. alcohol use disorders identification test) and substance use (drug abuse screening test-10) screening. Methods: This observational study included MBC data collected from November 2019 to March 2021. Patient-Reported Outcome Measures (PROMs) were examined to determine changes in symptomatology over the course of treatment, as well as symptom changes resulting from the pandemic. Patients were included in analyses if they completed at least one PROM in the MBC system. Results: A total of 2,145 patients actively participated in the MBC system completing at least one PROM, with engagement ranging from 35.07% to 83.50% depending on demographic factors, where completion rates were significantly different for age, payor status, and diagnostic group. Average baseline scores for new patients varied for the GAD-7, PHQ-9, and BASE-6. Within-person improvements in mental health before and after the pandemic were statistically significant for anxiety, depression, and psychological adjustment. Discussion: MBC is a helpful tool in determining treatment progress for patients engaging in telemedicine. This study showed that patients who engaged in psychiatric services incorporating PROMs had improvements in mental health during the COVID-19 pandemic. Additional research is needed exploring whether PROMs might serve as a protective or facilitative factor for those with mental illness during a crisis when in-person visits are not possible.

Use of Patient-Reported Outcome Measures to Assess the Effectiveness of Hybrid Psychiatric Visits.

OBJECTIVE: Little empirical evidence exists to support the effectiveness of hybrid psychiatric care, defined as care delivered through a combination of telephone, videoconferencing, and in-person visits. The authors aimed to investigate the effectiveness of hybrid psychiatric care compared with outpatient waitlist groups, assessed with patient-reported outcome measures (PROMs). METHOD: Participants were recruited from an adult psychiatry clinic waitlist on which the most common primary diagnoses were unipolar depression, generalized anxiety disorder, and bipolar disorder. Patients (N=148) were randomly assigned to one of two waitlist groups that completed PROMs once or monthly before treatment initiation. PROMs were used to assess symptoms of depression (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder-7 [GAD-7]), and daily psychological functioning (Brief Adjustment Scale-6 [BASE-6]). Patient measures were summarized descriptively with means, medians, and SDs and then compared by using the Kruskal-Wallis test; associated effect sizes were calculated. PROM scores for patients who received hybrid psychiatric treatment during a different period (N=272) were compared with scores of the waitlist groups. RESULTS: PROM assessments of patients who engaged in hybrid care indicated significant improvements in symptom severity compared with the waitlist groups, regardless of the number of PROMs completed while patients were on the waitlist. Between the hybrid care and waitlist groups, the effect size for the PHQ-9 score was moderate (d=0.66); effect sizes were small for the GAD-7 (d=0.46) and BASE-6 (d=0.45) scores. CONCLUSIONS: The findings indicate the clinical effectiveness of hybrid care and that PROMs can be used to assess this effectiveness.

Brief Adjustment Scale-6 for Measurement-Based Care: Psychometric Properties, Measurement Invariance, and Clinical Utility.

The Brief Adjustment Scale-6 (BASE-6) was recently developed for measuring general psychological functioning within measurement-based care (MBC). The present study further evaluated psychometric properties, generalizability to race/ethnic populations, and clinical utility of the BASE-6. Three adult samples, Sample 1: online community participants (n = 394); Sample 2: college students (n = 249); Sample 3: outpatient clinic clients (n = 80), were included. The results demonstrated a high level of internal consistency, good test-retest reliability, and convergent validity in all samples. The unidimensional structure of BASE-6 was confirmed and factorial invariance was established across groups. Finally, the BASE-6 captured change over time by demonstrating a large effect size of pre-post treatment changes and significant linear change in multilevel growth modeling. These results support the BASE-6 as a reliable and valid measure regardless of race/ethnicity and can sensitively detect clinical change over the course of the treatment. Thus, the BASE-6 appears to accurately monitor overall psychological adjustment.

Development and Feasibility of an Online Brief Emotion Regulation Training (BERT) Program for Emerging Adults.

Mental wellness is a critical component of healthy development in emerging adulthood and serves to protect against stress and promote resilience against psychopathology. Emotion regulation is a key mechanism for effective prevention because of its role in socio-emotional competence and its transdiagnostic significance for psychopathology. In this feasibility study, a brief, time and cost-effective emotion regulation training program for emerging adults (BERT) was developed and tested using the RE-AIM framework. Importantly, building interventions within the context of an implementation framework, such as the RE-AIM framework, enhances the chances that an intervention will be able to scale out and scale up. First, the brainwriting premortem method was utilized to refine program content, conducting focus groups a priori to identify potential program failures prior to program implementation. Undergraduate students (n = 12) attended four focus groups presenting initial program content. Four clinicians were also interviewed to determine program barriers. Qualitative analyses aggregated participant feedback to identify compliments, changes, and concerns about BERT and critical feedback was immediately implemented prior to initial testing. BERT was rooted in cognitive-behavioral practices and informed by the Gross model of emotion regulation. The 5-week program was then examined in a college sample (N = 42) to evaluate implementation (low attrition, high content engagement, favorable attitudes, low incidence of technical errors, costs), reach (enrollment and completion demographics comparable to the population in which recruitment took place), and efficacy (positive change in emotion regulation pre- to post-program). Of the recruited participants, 36 remained in the study where 27 completed at least 80% of program content. Repeated-measures ANOVAs exhibited significant improvements in emotion regulation, psychological distress, and negative affectivity, suggesting promising initial efficacy. Initial data provide support for feasibility and a future randomized control trial. BERT has potential significance for promoting healthy development as its brief electronic format reduced barriers and the program development process incorporated stakeholder feedback at multiple levels to inform better implementation and dissemination.

Integrating Measurement-Based Care into Treatment for Autism Spectrum Disorder: Insights from a Community Clinic.

Measurement-based care (MBC), an evidence-based approach that has demonstrated efficacy for improving treatment outcomes, has yet to be investigated in clients with Autism Spectrum Disorder. The current paper investigates the use of MBC in autistic (n = 20) and non-autistic (n = 20) clients matched on age, sex, and presenting problem. Results of change score analysis indicated that utilizing routine symptom monitoring can enhance treatment evaluation. Autistic clients participated in significantly more sessions, made significantly less progress, and were less compliant with MBC than non-autistic clients. Though hierarchical linear modeling demonstrated no significant differences in treatment slope, results indicated moderate effect size. These results inform the use of MBC in community clinics, highlighting policy implications and need for targeted measurement.

All in the Family: A Systematic Review of the Effect of Caregiver-Administered Autism Spectrum Disorder Interventions on Family Functioning and Relationships.

A number of intervention models aimed at addressing Autism Spectrum Disorder (ASD)-related behaviors require caregivers to perform intensive and oftentimes extended protocols (Bearss et al. in Clin Child Fam Psychol Rev 18(2):170-182, 2015). Though a number of research findings describe how characteristics of the child with ASD affect the mental health and stress experienced by caregivers and family members (Davis and Carter in J Autism Dev Disord 38(7):1278-1291, 2008; Tomanik et al. in J Intellect Dev Disabil 29(1):16-26, 2004), few studies investigate effects on overall family functioning and relationships among other family members. This review aimed to examine caregiver-delivered interventions as they relate to ASD, the impact of these caregiver-administered interventions on the family unit and family relationships, and potential future targets of treatments and treatment structures that include family members. The results of the review illustrate the nature of caregiver-administered interventions, which largely benefit family functioning and relationships.