Neurosurgery for psychiatric disorders: reviewing the past and charting the future.

Surgical techniques targeting behavioral disorders date back thousands of years. In this review, the authors discuss the history of neurosurgery for psychiatric disorders, starting with trephination in the Stone Age, progressing through the fraught practice of prefrontal lobotomy, and ending with modern neurosurgical techniques for treating psychiatric conditions, including ablative procedures, conventional deep brain stimulation, and closed-loop neurostimulation. Despite a tumultuous past, psychiatric neurosurgery is on the cusp of becoming a transformative therapy for patients with psychiatric dysfunction, with an ever-increasing evidence base suggesting reproducible and ethical therapeutic benefit.

Influence of Classroom-Level Factors on Implementation Fidelity During Scale-up of Evidence-Based Interventions.

As evidence-based interventions (EBIs) become more widely disseminated, fidelity of implementation (FOI) often wanes. This study explores the association between FOI and malleable variables within classrooms that could be targeted to optimize resources without compromising FOI as school-based EBIs are disseminated across real-world settings. We utilized process evaluation data from a national dissemination project of the Botvin LifeSkills Training (LST) middle school program, a universal prevention intervention shown to reduce substance use. The sample included 1,626 teachers in 371 schools across 14 states. Hierarchical linear models examined the relationship between observational measures of implementation factors and three domains of fidelity (e.g., adherence, student responsiveness, and quality of delivery). Findings suggest that curriculum modifications, student misbehavior, and shortage of time to implement the LST middle school program were factors most associated with lower FOI. Class size, access to program materials, and whether LST was delivered in a traditional classroom setting that is well-suited for instruction (versus in a less structured environment such as the school cafeteria) are less predictive. In scale-up of classroom-based universal interventions targeting behavioral health outcomes, our findings indicate that carefully vetting modifications, supporting classroom management strategies, and ensuring sufficient class time for implementation of highly interactive EBIs such as LST are important considerations. Since changes to EBIs are inevitable, efforts are needed to guide facilitators in making adjustments that improve program fit without compromising the essential intervention activities deemed necessary to produce desired outcomes.

The implementation potential of a method to monitor empirically-supported children's mental health treatment through claims data.

BACKGROUND: The delivery of evidence-supported treatments (EST) in children's mental health could be a valuable measure for monitoring mental healthcare quality; however, efforts to monitor the use of EST in real world systems are hindered by the lack of pragmatic methods. This mixed methods study examined the implementation and agency response rate of a pragmatic, claims-based measure of EST designed to be applied as a universal quality measure for child psychotherapy encounters in a state Medicaid system. METHODS: Implementation potential of the EST measure was assessed with healthcare leader rankings of the reporting method's acceptability, appropriateness and feasibility (n = 53), and post-implementation ratings of EST rate accuracy. Ability of the healthcare system to monitor EST through claims was measured by examining the agency responsivity in using the claims-based measure across 98 Medicaid-contracted community mental health (CMH) agencies in Washington State. RESULTS: The analysis found the reporting method had high implementation potential. The method was able to measure the use of an EST for 83% of children covered by Medicaid with 58% CMH agencies reporting > 0 ESTs in one quarter. Qualitative analyses revealed that the most significant barrier to reporting ESTs was the operability of electronic health record systems and agencies' mixed views regarding the accuracy and benefits of reporting. CONCLUSIONS: Measurement of child mental health ESTs through Medicaid claims reporting has acceptable implementation potential and promising real world responsiveness from CMH agencies in one state. Variation in reporting by agency site and low to moderate perceived value by agency leaders suggests the need for additional implementation supports for wider uptake.

The Effects of Focal Electrically Administered Seizure Therapy Compared With Ultrabrief Pulse Right Unilateral Electroconvulsive Therapy on Suicidal Ideation: A 2-Site Clinical Trial.

BACKGROUND: Preliminary data suggest that focal electrically administered seizure therapy (FEAST) has antidepressant effects and less adverse cognitive effects than traditional forms of electroconvulsive therapy (ECT). This study compared the impact of FEAST and ultrabrief pulse, right unilateral (UB-RUL) ECT on suicidal ideation. METHODS: At 2 sites, patients in a major depressive episode were treated openly with FEAST or UB-RUL ECT, depending on their preference. The primary outcome measure was scores on the Beck Scale for Suicide Ideation (SSI). Scores on the suicide item of the Hamilton Rating Scale for Depression (HRSD-SI) provided a secondary outcome measure. RESULTS: Thirty-nine patients were included in the intent-to-treat sample (FEAST, n = 20; UB-RUL ECT, n = 19). Scores on both the SSI and HRSD-SI were equivalently reduced with both interventions. Both responders and nonresponders to the interventions showed substantial reductions in SSI and HRSD-SI scores, although the magnitude of improvement was greater among treatment responders. CONCLUSIONS: Although limited by the open-label, nonrandomized design, FEAST showed comparable effects on suicidal ideation when compared with routine use of UB-RUL ECT. These results are encouraging and support the need for further research and a noninferiority trial.

Partnering for Success: Factors Impacting Implementation of a Cross-Systems Collaborative model Between Behavioral Health and Child Welfare.

Cross-system implementation efforts can support needed mental health (MH) service utilization among children involved in the child welfare (CW) system. The Partnering for Success (PfS) initiative is one such effort that promotes greater collaboration between the CW and MH providers by building capacity within and across each system. Frontline CW providers learn to accurately identify child MH treatment targets, link families to locally-provided evidence-based treatments (EBTs), and monitor treatment progress. Concurrently, local MH providers are trained along with CW workers to utilize Cognitive Behavioral Therapy plus Trauma-Focused CBT (CBT +), a common elements training and consultation approach focusing on typical MH issues for CW-involved children: Anxiety, Depression, Behavioral Problems, and Traumatic Stress. Finally, agency leadership receive support around promoting implementation and sustainment. This paper examines factors identified by participating CW and MH staff which impacted PfS implementation. Twenty-nine frontline, supervisory, and executive CW and MH providers were interviewed via audio-recorded web-based calls in six focus groups and 10 individual interviews. Factors facilitating implementation success included training/consultation, support from supervisors and agency leadership, improved referral processes, high quality relationships and communication between CW and MH frontline staff, PfS tools and resources, opportunities to use PfS, as well as buy-in from providers and families. Implementation barriers included poor communication between CW and MH providers, conflicts over role expectations, workload and turnover challenges, lack of buy-in, as well as provider (e.g., not aligned with CBT +) and client characteristics (e.g., frequent crises).

Measurement Based Care in Child Welfare-Involved Children and Youth: Reliability and Validity of the PSC-17.

This study evaluates whether the psychometric properties of the Pediatric Symptoms Checklist-17 (PSC-17), a common behavioral health measure typically used as a dichotomous screening tool for mental health needs, support its use as a continuous measure for tracking behavioral health over time. A total of 6492 foster parents of children and youth aged 5.5-17 completed the PSC-17. Convergent and discriminant validity was assessed by comparing raw PSC-17 subscale scores with associated outcomes (e.g. psychiatric diagnoses). Long-term test-retest reliability was assessed over 6 months. Scores on the PSC-17 demonstrated good convergent and divergent validity. PSC-17 subscale scores were most strongly associated with analogous diagnoses. Test-retest reliability was moderate, as expected for a time window of this length. This study provides moderate support for the psychometric qualities of the PSC-17 when used with children and youth in the child welfare system as a continuous measure of psychosocial functioning over time.

Identifying Psychosocial Problems Among Children and Youth in the Child Welfare System Using the PSC-17: Exploring Convergent and Discriminant Validity with Multiple Informants.

Youth who enter foster care are at risk of mental health need, but questions arise as to the validity of their self-reported symptomatology. This study examines the screening validity of the youth-report version of the Pediatric Symptom Checklist-17 (PSC-17) in a child welfare population. Data come from 2389 youth who completed a version of the PSC-17 adapted for youth report, and their biological and foster parents who completed the parent-report version. Youth also completed a shortened version of the Screen for Child Anxiety Related Disorders (SCARED). Convergent and discriminant validity of the PSC-17 was assessed using multi-trait multi-method matrices. The PSC-17's internalizing subscale was strongly correlated, attention subscale was moderately correlated, and externalizing subscale was weakly correlated with the SCARED's anxiety and PTSD subscales. Comparing youth and foster parent scores, the PSC-17 had moderate convergent validity and weak/fair discriminant validity. Comparing youth, foster parent, and biological parent scores, the PSC-17 had moderate convergent validity and weak/fair discriminant validity. The current study provides some support for the validity of the PSC-17 for the population of youth in foster care.

Agreement and Discrepancy Between Supervisor and Clinician Alliance: Associations with Clinicians' Perceptions of Psychological Climate and Emotional Exhaustion.

Despite increasing interest in supervision as a leverage point for bolstering public mental health services, the potential influence of supervisory alliance on organizations and direct service providers remains understudied, particularly in the context of supporting evidence-based treatment (EBT) use. This study examined agreement and discrepancy between supervisor and clinician ratings of alliance associated with clinicians' perceptions of psychological climate and emotional exhaustion. Results indicated that discrepancies in alliance ratings were common and associated with clinicians' perceptions of psychological climate. These findings have important implications for collaboration among supervisors and clinicians within a community mental health organizational context and the provision of EBTs.

Evidence Base Update for Psychosocial Treatments for Children and Adolescents Exposed to Traumatic Events.

Child and adolescent trauma exposure is prevalent, with trauma exposure-related symptoms, including posttraumatic stress, depressive, and anxiety symptoms often causing substantial impairment. This article updates the evidence base on psychosocial treatments for child and adolescent trauma exposure completed for this journal by Silverman et al. (2008). For this review, we focus on 37 studies conducted during the seven years since the last review. Treatments are grouped by overall treatment family (e.g., cognitive behavioral therapy), treatment modality (e.g., individual vs. group), and treatment participants (e.g., child only vs. child and parent). All studies were evaluated for methodological rigor according to Journal of Clinical Child & Adolescent Psychology evidence-based treatment evaluation criteria (Southam-Gerow & Prinstein, 2014), with cumulative designations for level of support for each treatment family. Individual CBT with parent involvement, individual CBT, and group CBT were deemed well-established; group CBT with parent involvement and eye movement desensitization and reprocessing (EMDR) were deemed probably efficacious; individual integrated therapy for complex trauma and group mind-body skills were deemed possibly efficacious; individual client-centered play therapy, individual mind-body skills, and individual psychoanalysis were deemed experimental; and group creative expressive + CBT was deemed questionable efficacy. Advances in the evidence base, with comparisons to the state of the science at the time of the Silverman et al. (2008) review, are discussed. Finally, we present dissemination and implementation challenges and areas for future research.

Developing a Quality Assurance System for Multiple Evidence Based Practices in a Statewide Service Improvement Initiative.

Efforts to implement evidence based practices (EBP) are increasingly common in child-serving systems. However, public systems undertaking comprehensive improvement efforts that aim to increase availability of multiple practices at the same time may struggle to build comprehensive and user-friendly strategies to develop the workforce and encourage adoption, faithful implementation, and sustainability of selected EBPs. Given that research shows model adherence predicts positive outcomes, one critical EBP implementation support is systematic quality, fidelity, and compliance monitoring. This paper describes the development and initial implementation of a quality assurance framework for a statewide EBP initiative within child welfare. This initiative aimed to improve provider practice and monitor provider competence and compliance across four different EBPs, and to inform funding and policy decisions. The paper presents preliminary data as an illustration of lessons learned during the quality monitoring process and concludes with a discussion of the promise and challenges of developing and applying a multi-EBP quality assurance framework for use in public systems.

The Juggling Act of Supervision in Community Mental Health: Implications for Supporting Evidence-Based Treatment.

Supervisors are an underutilized resource for supporting evidence-based treatments (EBTs) in community mental health. Little is known about how EBT-trained supervisors use supervision time. Primary aims were to describe supervision (e.g., modality, frequency), examine functions of individual supervision, and examine factors associated with time allocation to supervision functions. Results from 56 supervisors and 207 clinicians from 25 organizations indicate high prevalence of individual supervision, often alongside group and informal supervision. Individual supervision serves a wide range of functions, with substantial variation at the supervisor-level. Implementation climate was the strongest predictor of time allocation to clinical and EBT-relevant functions.

Expanded Safety and Efficacy Data for a New Method of Performing Electroconvulsive Therapy: Focal Electrically Administered Seizure Therapy.

OBJECTIVE: Electroconvulsive therapy (ECT) is the most rapid and effective antidepressant treatment but with concerns about cognitive adverse effects. A new form of ECT, focal electrically administered seizure therapy (FEAST), was designed to increase the focality of stimulation and better match stimulus parameters with neurophysiology. We recently reported on the safety and feasibility of FEAST in a cohort (n = 17) of depressed patients. We now report on the safety, feasibility, preliminary efficacy, and cognitive effects of FEAST in a new cohort. METHODS: Open-label FEAST was administered to 20 depressed adults (6 men; 3 with bipolar disorder; age 49.1 ± 10.6 years). Clinical and cognitive assessments were obtained at baseline and end of course. Time to orientation recovery was assessed at each treatment. Nonresponders switched to conventional ECT. RESULTS: Participants tolerated the treatment well with no dropouts. Five patients (25%) transitioned from FEAST to conventional ECT due to inadequate response. After FEAST (mean, 9.3 ± 3.5 sessions; range, 4-14), there was a 58.1% ± 36.0% improvement in Hamilton Rating Scale for Depression scores compared with that in the baseline (P < 0.0001); 13 (65%) of 20 patients met response criteria, and 11 (55%) of 20 met remission criteria. Patients achieved reorientation (4 of 5 items) in 4.4 ± 3.0 minutes (median, 4.5 minutes), timed from eyes opening. There was no deterioration in neuropsychological measures. CONCLUSIONS: These findings provide further support for the safety and efficacy of FEAST. The remission and response rates were in the range found using conventional ECT, and the time to reorientation may be quicker. However, without a randomized comparison group, conclusions are tentative.

An Equity-Focused Assessment of Evidence-Based Parenting Intervention Research.

Evidence-based parenting interventions (EBPI) support children and families to promote resilience, address emotional and behavioral concerns, and prevent or address issues related to child maltreatment. Critiques of EBPIs include concerns about their relevance and effectiveness for diverse populations when they are implemented at population scale. Research methods that center racial equity and include community-based participatory approaches have the potential to address some of these concerns. The purpose of the present review was to document the extent to which methods associated with promoting racial equity in research have been used in studies that contribute to the evidence base for programs that meet evidentiary standards for a clearinghouse that was developed to support the Family First Prevention Services Act in the United States. We developed a coding system largely based on the Culturally Responsive Evaluation model. A sample of 47 papers that are part of the evidence base for ten in-home parent skill-based programs were reviewed and coded. Only three of 28 possible codes were observed to occur in over half of the studies (including race/ethnicity demographic characteristics, conducting measure reliability for the study sample, and including information on socioeconomic status). Although the overall presence of equity-informed methods was low, a positive trend was observed over time. This review highlights ways in which rigorous research can incorporate racial equity into the planning, design, execution, and interpretation and dissemination of programs of study. We posit that doing so improves the external validity of studies while maintaining high-quality research that can contribute to an evidence base.

The Impact of COVID-19 on Brain Stimulation Therapy.

Among the far-reaching effects of the COVID-19 pandemic has been restricted access to safe and effective forms of psychiatric treatment. Focusing on electroconvulsive therapy and transcranial magnetic stimulation, we review the pandemic's impact on brain stimulation therapy by asking 3 fundamental questions-Where have we been? How are we doing? And where are we going?

Developing the mental health workforce: review and application of training approaches from multiple disciplines.

Strategies specifically designed to facilitate the training of mental health practitioners in evidence-based practices (EBPs) have lagged behind the development of the interventions themselves. The current paper draws from an interdisciplinary literature (including medical training, adult education, and teacher training) to identify useful training and support approaches as well as important conceptual frameworks that may be applied to training in mental health. Theory and research findings are reviewed, which highlight the importance of continued consultation/support following training workshops, congruence between the training content and practitioner experience, and focus on motivational issues. In addition, six individual approaches are presented with careful attention to their empirical foundations and potential applications. Common techniques are highlighted and applications and future directions for mental health workforce training and research are discussed.

Translating economic evaluations into financing strategies for implementing evidence-based practices.

BACKGROUND: Implementation researchers are increasingly using economic evaluation to explore the benefits produced by implementing evidence-based practices (EBPs) in healthcare settings. However, the findings of typical economic evaluations (e.g., based on clinical trials) are rarely sufficient to inform decisions about how health service organizations and policymakers should finance investments in EBPs. This paper describes how economic evaluations can be translated into policy and practice through complementary research on financing strategies that support EBP implementation and sustainment. MAIN BODY: We provide an overview of EBP implementation financing, which outlines key financing and health service delivery system stakeholders and their points of decision-making. We then illustrate how economic evaluations have informed decisions about EBP implementation and sustainment with three case examples: (1) use of Pay-for-Success financing to implement multisystemic therapy in underserved areas of Colorado, USA, based in part on the strength of evidence from economic evaluations; (2) an alternative payment model to sustain evidence-based oncology care, developed by the US Centers for Medicare and Medicaid Services through simulations of economic impact; and (3) use of a recently developed fiscal mapping process to collaboratively match financing strategies and needs during a pragmatic clinical trial for a newly adapted family support intervention for opioid use disorder. CONCLUSIONS: EBP financing strategies can help overcome cost-related barriers to implementing and sustaining EBPs by translating economic evaluation results into policy and practice. We present a research agenda to advance understanding of financing strategies in five key areas raised by our case examples: (1) maximize the relevance of economic evaluations for real-world EBP implementation; (2) study ongoing changes in financing systems as part of economic evaluations; (3) identify the conditions under which a given financing strategy is most beneficial; (4) explore the use and impacts of financing strategies across pre-implementation, active implementation, and sustainment phases; and (5) advance research efforts through strong partnerships with stakeholder groups while attending to issues of power imbalance and transparency. Attention to these research areas will develop a robust body of scholarship around EBP financing strategies and, ultimately, enable greater public health impacts of EBPs.

Brain stimulation in zero gravity: transcranial magnetic stimulation (TMS) motor threshold decreases during zero gravity induced by parabolic flight.

We are just beginning to understand how spaceflight may impact brain function. As NASA proceeds with plans to send astronauts to the Moon and commercial space travel interest increases, it is critical to understand how the human brain and peripheral nervous system respond to zero gravity. Here, we developed and refined head-worn transcranial magnetic stimulation (TMS) systems capable of reliably and quickly determining the amount of electromagnetism each individual needs to detect electromyographic (EMG) threshold levels in the thumb (called the resting motor threshold (rMT)). We then collected rMTs in 10 healthy adult participants in the laboratory at baseline, and subsequently at three time points onboard an airplane: (T1) pre-flight at Earth gravity, (T2) during zero gravity periods induced by parabolic flight and (T3) post-flight at Earth gravity. Overall, the subjects required 12.6% less electromagnetism applied to the brain to cause thumb muscle activation during weightlessness compared to Earth gravity, suggesting neurophysiological changes occur during brief periods of zero gravity. We discuss several candidate explanations for this finding, including upward shift of the brain within the skull, acute increases in cortical excitability, changes in intracranial pressure, and diffuse spinal or neuromuscular system effects. All of these possible explanations warrant further study. In summary, we documented neurophysiological changes during brief episodes of zero gravity and thus highlighting the need for further studies of human brain function in altered gravity conditions to optimally prepare for prolonged microgravity exposure during spaceflight.

A two-site, open-label, non-randomized trial comparing Focal Electrically-Administered Seizure Therapy (FEAST) and right unilateral ultrabrief pulse electroconvulsive therapy (RUL-UBP ECT).

BACKGROUND: Focal Electrically-Administered Seizure Therapy (FEAST) is a form of electroconvulsive therapy (ECT) that spatially focuses the electrical stimulus to initiate seizure activity in right prefrontal cortex. Two open-label non-comparative studies suggested that FEAST has reduced cognitive side effects when compared to historical data from other forms of ECT. In two different ECT clinics, we compared the efficacy and cognitive side effects of FEAST and Right Unilateral Ultrabrief Pulse (RUL-UBP) ECT. METHODS: Using a non-randomized, open-label design, 39 depressed adults were recruited after referral for ECT. Twenty patients received FEAST (14 women; age 45.2 ± 12.7), and 19 received RUL-UBP ECT (16 women; age 43.2 ± 16.4). Key cognitive outcome measures were the postictal time to reorientation and the Columbia University Autobiographical Memory Interview: Short-Form (CUAMI-SF). Antidepressant effects were assessed using the Hamilton Rating Scale for Depression (HRSD24). RESULTS: In the Intent-to-treat sample, a repeated measures mixed model suggested no between group difference in HRSD24 score over time (F1,35 = 0.82, p = 0.37), while the response rate favored FEAST (FEAST: 65%; RUL-UBP ECT: 57.9%), and the remission rate favored RUL-UBP ECT (FEAST: 35%; RUL-UBP ECT: 47.4%). The FEAST group had numeric superiority in average time to reorientation (FEAST: 6.6 ± 5.0 min; RUL-UBP ECT: 8.8 ± 5.8 min; Cohens d = 0.41), and CUAMI-SF consistency score (FEAST: 69.2 ± 14.2%; RUL-UBP ECT: 63.9 ± 9.9%; Cohens d = 0.43); findings that failed to meet statistical significance. CONCLUSIONS: FEAST exerts similar efficacy relative to an optimal form of conventional ECT and may have milder cognitive side effects. A blinded, randomized, non-inferiority trial is needed.