Different factors identified by stakeholder group for barriers and facilitators to measurement-based care implementation in behavioral health clinics.

INTRODUCTION: Despite the benefits of measurement-based care (MBC) in the behavioral health setting, there have been difficulties in implementation and low saturation. Although barriers and facilitators to MBC implementation have been identified, research has generally only included the perspective of one stakeholder group. The current study aims to examine the similarities and differences-by stakeholder group-in the identified barriers to and facilitators of implementing MBC in the behavioral health setting. METHOD: A purposeful sampling approach was used to recruit and conduct interviews and focus groups with stakeholders (clinicians, clinic leaders, and administrative staff) from four behavioral health clinics at an academic medical center that is part of a larger healthcare system. The data coding process included a directed content analytic approach whereby the coding team used an iterative process to analyze deidentified transcripts starting with a codebook based on the Consolidated Framework for Implementation Research (CFIR) constructs. RESULTS: A total of 31 clinicians, 11 clinic leaders, and 8 administrative staff participated in the interviews and focus groups. There was convergence among all stakeholder regarding which CFIR constructs were identified as barriers and facilitators, but there were differences in the specific thematic factors identified by stakeholders as barriers and facilitators within each of these implementation constructs. The barriers and facilitators that stakeholders identified within each CFIR construct were often connected to their specific role in implementing MBC. CONCLUSION: Collecting information on barriers and facilitators to MBC implementation from the multiple stakeholders involved in the process may enhance successful implementation of MBC given the variation between groups in identified thematic factors. Administrative staff perspectives, which have not been reported in the literature, may be of particular importance in planning for successful MBC implementation.

Ensuring the fit of an evidence-based curriculum for high-risk Latina young mothers using implementation science.

Conduct a comprehensive needs assessment to evaluate the fit of a Cognitive Behavioral Theory (CBT) curriculum implemented within a community organization and inform possible adaptations to fit the mental health difficulties of high-risk Latina young mothers. The PRECEDE-PROCEED implementation framework guided the assessment and results. Focus groups were conducted with high-risk Latina young mothers and staff members to assess the priority mental health problems, environmental stressors and factors contributing and maintaining these difficulties, and existing resources that could be leveraged to address them. Latina young mothers experience a variety of mental health needs and immigration and interpersonal-related stressors. The organization's existing CBT curriculum was found to be feasible and a good fit for the target population. Proposed minor adaptations included a focus on parenting. Results support the robust effects of CBT interventions, including when delivered by paraprofessionals to a high-risk population in a low-resource community setting.

Effectiveness of a Modular Cognitive-Behavioral Skills Curriculum in High-Risk Justice-Involved Youth.

The aim of this study was to evaluate the effectiveness of a flexible modular cognitive-behavioral theory (CBT) skills curriculum delivered by paraprofessionals in a community organization targeting high-risk justice-involved youth. Programmatic data were collected from 980 high-risk young men (Mage, 21.12; SD, 2.30), and Cox proportional hazards regression was used. The results showed that compared with young men with no CBT encounters, those with one or more CBT encounters had a 66% (hazard ratio [HR], 0.34; 95% confidence interval [CI], 0.28-0.42; p < 0.001) lower risk of unenrolling from programming, 65% (HR, 1.65; 95% CI, 1.29-2.12; p < 0.001) higher risk of obtaining a job, and no difference in risk of engaging in new criminal activity while enrolled in programming (HR, 0.99; 95% CI, 0.78-1.25; p = 0.918), despite higher risk factors. Training paraprofessionals to deliver CBT skills to high-risk populations is effective and has scalability potential.

The value of implementation frameworks: Using the active implementation frameworks to guide system-wide implementation of Collaborative Problem Solving.

In the last decade, many implementation frameworks have emerged that consolidate the research on implementation science, guiding purveyors and service agencies in improving implementation of evidence-based practices (EBPs). In this paper, we describe how the purveyor of one EBP utilized the active implementation frameworks (AIFs) to define and standardize strategies for site-wide implementation. We illustrate what implementation looked like before and after using AIFs to understand implementation, as well as some ways in which using the AIFs helped the purveyor identify, and then overcome, barriers to implementation. This paper provides a model for others who seek to use AIFs to guide their implementation practices, or more broadly, an illustration of how to use any implementation framework to ensure best practices in implementation.

Barriers and Facilitators to Implementing a Short-Term Transdiagnostic Mental Health Treatment for Homeless Persons.

Despite the significant mental health needs and comorbidity in homeless individuals, there is a "science-practice gap" between the available evidence-based treatments (EBTs) and their lack of use in community health centers servicing homeless populations. To address this gap, it is imperative to evaluate and attend to the contextual factors that influence the implementation process of EBTs before their integration into routine care. The study aims to evaluate the barriers and facilitators to implementing a transdiagnostic EBT in a community health center serving homeless individuals. The results of the thematic analyses (7 focus groups, 67 participants) yielded 8 themes for barriers and 10 themes for facilitators to implementation. The findings of the current study highlight common tensions faced by community programs and clinicians when working toward integrating EBTs across different types of populations, and those unique to homeless persons. Results can inform subsequent strategies used in implementing EBTs.

Cognitive Processing Therapy for Spanish-speaking Latinos: A Formative Study of a Model-Driven Cultural Adaptation of the Manual to Enhance Implementation in a Usual Care Setting.

OBJECTIVE: As part of a larger implementation trial for cognitive processing therapy (CPT) for posttraumatic stress disorder (PTSD) in a community health center, we used formative evaluation to assess relations between iterative cultural adaption (for Spanish-speaking clients) and implementation outcomes (appropriateness and acceptability) for CPT. METHOD: Qualitative data for the current study were gathered through multiple sources (providers: N = 6; clients: N = 22), including CPT therapy sessions, provider fieldnotes, weekly consultation team meetings, and researcher fieldnotes. Findings from conventional and directed content analysis of the data informed refinements to the CPT manual. RESULTS: Data-driven refinements included adaptations related to cultural context (i.e., language, regional variation in wording), urban context (e.g., crime/violence), and literacy level. Qualitative findings suggest improved appropriateness and acceptability of CPT for Spanish-speaking clients. CONCLUSION: Our study reinforces the need for dual application of cultural adaptation and implementation science to address the PTSD treatment needs of Spanish-speaking clients.

Treating Posttraumatic Stress Disorder in Diverse Settings: Recent Advances and Challenges for the Future.

Racial and ethnic minorities are at high risk for developing posttraumatic stress disorder (PTSD) after experiencing a traumatic event and are less likely to receive evidence-based treatment for their symptoms. There is a growing body of literature showing that culturally appropriate interventions result in greater uptake, symptom reduction, and sustained treatment gains. This article review explores new findings in the cultural understanding of PTSD among racial and ethnic minorities. We first review recent advances in the understanding of PTSD symptomotology. Next, we provide overview of trials demonstrating efficacy and effectiveness of cognitive processing therapy (CPT), prolonged exposure (PE), and trauma-focused cognitive-behavioral therapy (TF-CBT) in diverse communities. Then, we discuss specific implementation strategies common across intervention trials used to increase feasibility, acceptability, adoption, and sustainability. Last, we discuss areas for future research and dissemination efforts.

Association of premenstrual syndrome and premenstrual dysphoric disorder with bulimia nervosa and binge-eating disorder in a nationally representative epidemiological sample.

OBJECTIVE: Bulimia nervosa (BN) and binge-eating disorder (BED) are associated with significant health impairment. Premenstrual syndrome (PMS) and premenstrual dysphoric disorder (PMDD) comprise both psychological (disturbances in mood and affect) and physiological (bloating and changes in appetite) symptoms that may trigger binge-eating and/or purging. METHOD: Female participants were drawn from the Collaborative Psychiatric Epidemiological Surveys, conducted from 2001 to 2003. Weighted multivariable logistic regression modeled the association between lifetime PMS and PMDD and lifetime odds of BN or BED. RESULTS: Among 8,694 participants, 133 (1.0%) had BN and 185 (1.8%) BED. Additionally, 366 (4.2%) had PMDD and 3,489 (42.4%) had PMS. Prevalence of PMDD and PMS were 17.4 and 55.4% among those with BN, 10.7 and 48.9% among those with BED and 3.4 and 59.1% among those with subthreshold BED. After adjustment for age, race/ethnicity, income, education, body mass index, age at menarche, birth control use, and comorbid mental health conditions, PMDD was associated with seven times the odds of BN (OR 7.2, 95% CI 2.3, 22.4) and PMS with two times the odds of BN (OR 2.5, 95% CI 1.1, 5.7). Neither PMDD nor PMS were significantly associated with BED. DISCUSSION: Women with PMS and PMDD have a higher odds of BN, independent of comorbid mental health conditions. PMS and PMDD may be important comorbidities to BN to consider in clinical settings, and future research should investigate whether PMS and PMDD affect the onset and duration of bulimic symptoms as well as the potential for shared risk factors across disorders. © 2016 Wiley Periodicals, Inc.(Int J Eat Disord 2016; 49:641-650).

PTSD and Romantic Relationship Satisfaction: Cluster- and Symptom-Level Analyses.

Previous studies have demonstrated bidirectional associations between posttraumatric stress disorder (PTSD) and romantic relationship dissatisfaction. Most of these studies were focused at the level of the disorder, examining the association between relationship dissatisfaction and having a diagnosis of PTSD or the total of PTSD symptoms endorsed. This disorder-level approach is problematic for trauma theorists who posit symptom-level mechanisms for these effects. In the present study, we examined the prospective, bidirectional associations between PTSD symptom clusters (e.g., reexperiencing) and relationship satisfaction using the data from 101 previously studied individuals who had had a recent motor vehicle accident. We also conducted exploratory analyses examining the prospective, bidirectional associations between individual PTSD symptoms and relationship satisfaction. Participants had completed the PTSD Checklist-Civilian Version and the Relationship Assessment Scale at 4, 10, and 16 weeks after the MVA. We performed time-lagged mixed-effects regressions to examine the effect of lagged relationship satisfaction on PTSD clusters and symptoms, and vice versa. No cluster effects were significant after controlling for a false discovery rate. Relationship satisfaction predicted prospective decreases in reliving the trauma (d = 0.42), emotional numbness (d = 0.46), and irritability (d = 0.49). These findings were consistent with the position that relationship satisfaction affects PTSD through symptom-level mechanisms.

Anxiety sensitivity in bereaved adults with and without complicated grief.

Complicated grief (CG) is a bereavement-specific syndrome chiefly characterized by symptoms of persistent separation distress. Physiological reactivity to reminders of the loss and repeated acute pangs or waves of severe anxiety and psychological pain are prominent features of CG. Fear of this grief-related physiological arousal may contribute to CG by increasing the distress associated with grief reactions and increasing the likelihood of maladaptive coping strategies and grief-related avoidance. Here, we examined anxiety sensitivity (AS; i.e., the fear of anxiety-related sensations) in two studies of bereaved adults with and without CG. In both studies, bereaved adults with CG exhibited elevated AS relative to those without CG. In study 2, AS was positively associated with CG symptom severity among those with CG. These findings are consistent with the possibility that AS contributes to the development or maintenance of CG symptoms.

Complicated grief symptoms in anxiety disorders: prevalence and associated impairment.

BACKGROUND: Previous research has identified high rates of comorbid anxiety disorders among individuals presenting with primary CG. In the present study, we examined the prevalence of comorbid CG in bereaved primary anxiety disorder (AD) patients compared to bereaved healthy controls. We also examined the impairment associated with comorbid CG in AD. METHODS: Participants were 242 bereaved adults (mean (SD) age = 41.5 (13.1), 44.2% women) with a primary AD diagnosis, including generalized anxiety disorder (GAD; n = 57), panic disorder (PD; n = 49), posttraumatic stress disorder (PTSD; n = 29), and generalized social anxiety disorder (GSAD; n = 107), as well as 155 bereaved healthy controls with no current DSM-IV Axis I diagnosis (mean (SD) age = 43.0 (13.6), 51.0% women). CG symptoms were measured using the 19-item inventory of complicated grief (ICG), with threshold CG defined as an ICG score of ≥30. Quality of life and functional impairment were assessed with the Quality of Life Enjoyment and Satisfaction Questionnaire (Q-LES-Q) and the Range of Impaired Functioning Tool (LIFE-RIFT), respectively. RESULTS: Participants with primary ADs had significantly higher rates of threshold CG symptoms than bereaved controls (12.0% vs. 0.65%; Fisher's Exact P < 0.001). Rates of threshold CG were significantly elevated for each AD when compared to bereaved controls. After adjustment for age, sex, education, and comorbid major depressive disorder, threshold CG was associated with lower quality of life (ß = -0.140, P = 0.023) and greater impairment (ß = 0.141, P = 0.035) among individuals with AD. CONCLUSIONS: Our findings suggest that threshold CG is of clinical relevance in bereaved individuals with a primary anxiety disorder. Screening for CG in patients with ADs may be warranted.

Sleep quality predicts treatment outcome in CBT for social anxiety disorder.

BACKGROUND: Sleep quality may be an important, yet relatively neglected, predictor of treatment outcome in cognitive-behavioral therapy (CBT) for anxiety disorders. Specifically, poor sleep quality may impair memory consolidation of in-session extinction learning. We therefore examined sleep quality as a predictor of treatment outcome in CBT for social anxiety disorder and the impact of d-cycloserine (DCS) on this relationship. METHODS: One hundred sixty-nine participants with a primary diagnosis of DSM-IV generalized social anxiety disorder were recruited across three sites. Participants were enrolled in 12 weeks of group CBT. Participants randomly received 50 mg of DCS (n = 87) or pill placebo (n = 82) 1 hr prior to sessions 3-7. Participants completed a baseline measure of self-reported sleep quality and daily diaries recording subjective feelings of being rested upon wakening. Outcome measures including social anxiety symptoms and global severity scores were assessed at each session. RESULTS: Poorer baseline sleep quality was associated with slower improvement and higher posttreatment social anxiety symptom and severity scores. Moreover, patients who felt more "rested" after sleeping the night following a treatment session had lower levels of symptoms and global severity at the next session, controlling for their symptoms and severity scores the previous session. Neither of these effects were moderated by DCS condition. CONCLUSIONS: Our findings suggest that poor sleep quality diminishes the effects of CBT for social anxiety disorder and this relation is not attenuated by DCS administration. Therapeutic attention to sleep quality prior to initiation of CBT and during the acute treatment phase may be clinically indicated.

Pre-treatment amygdala activation and habituation predict symptom change in post-traumatic stress disorder.

Trauma-focused psychotherapy approaches are the first-line treatment option for post-traumatic stress disorder (PTSD); however, up to a third of patients remain symptomatic even after completion of the treatment. Predicting which patients will respond to a given treatment option would support personalized treatments and improve the efficiency of healthcare systems. Although previous neuroimaging studies have examined possible pre-treatment predictors of response to treatment, the findings have been somewhat inconsistent, and no other study has examined habituation to stimuli as a predictor. In this study, 16 treatment-seeking adults (MAge = 43.63, n = 10 women) with a primary diagnosis of PTSD passively viewed pictures of emotional facial expressions during functional magnetic resonance imaging (fMRI). After scanning, participants rated facial expressions on both valence and arousal. Participants then completed eight weekly sessions of prolonged exposure (PE) therapy. PTSD symptom severity was measured before and after treatment. Overall, participants showed symptomatic improvement with PE. Consistent with hypotheses, lesser activation in the amygdala and greater activation in the ventromedial prefrontal cortex during the presentation of fearful vs. happy facial expressions, as well as a greater decline in amygdala activation across blocks of fearful facial expressions at baseline, were associated with greater reduction of PTSD symptoms. Given that the repeated presentation of emotional material underlies PE, changes in brain responses with repeated stimulus presentations warrant further studies as potential predictors of response to exposure therapies.

Traumatic experiences in individuals with body dysmorphic disorder.

Individuals with body dysmorphic disorder (BDD) are excessively concerned about perceived defects in their appearance (e.g., blemishes on their skin). BDD is a severe mental disorder often associated with increased suicidality as well as significant social and occupational interference (e.g., J Clin Psychiatry 2005;66:717-725). Recently, investigators have begun to explore variables that might function as risk factors in the development of BDD, such as traumatic experiences (e.g., Child Abuse Negl 2006;30:1105-1115). As such, one of the goals of the current study was to examine the role of early-life sexual, physical, or emotional abuse in BDD. Specifically, the Traumatic Stress Institute Life Event Questionnaire (Treat Abuse Today 1992;2:9-11) was used to examine whether individuals with BDD (n = 18) self-reported having experienced more traumatic events than mentally healthy controls (n = 19). The BDD group reported more retrospective experiences of sexual and physical abuse in childhood or adolescence than did healthy controls. Surprisingly, there was no significant group difference in reports of emotional abuse in early life. This study provides preliminary evidence of the importance of examining abuse as a potential risk factor in the development of BDD.

Improved emotion regulation following a trauma-informed CBT-based intervention associates with reduced risk for recidivism in justice-involved emerging adults.

Objective: Male youth who have been involved in the juvenile legal system have disproportionate rates of trauma and violence exposure. Many justice-involved youth have untreated mental illness, with an estimated 66% of young men who are incarcerated meeting criteria for at least one mental health disorder, including posttraumatic stress disorder (PTSD), depression, and substance abuse. While Cognitive Behavioral Therapy (CBT) approaches are considered among effective evidence-based treatments for addressing and treating behavioral and emotional difficulties, male youth with a history of incarceration and youth who are at risk for (re)incarceration, violence, emotion dysregulation, and trauma face significant barriers in accessing these services. Methods: Roca, Inc. (Roca), an internationally recognized organization moving the needle on urban violence by working relentlessly with young people at the center of violence in Massachusetts and Maryland, employs a trauma-informed CBT-based skills curriculum and approach in their intervention model, to improve youths' educational, employment, parenting, and life skills opportunities, while decreasing risk for recidivism, addressing trauma and increasing skills for emotion regulation. The aim of this analysis was to assess the effectiveness of Roca's trauma-informed CBT skills curriculum on youths' emotional and behavioral outcomes. We analyzed data from over 300 participating emerging adult men from four sites in Massachusetts and one site in Baltimore, Maryland who had at least three series of data collection across multiple skills-based sessions. Results: We found improvements in outcomes in overall mean scores related to decreased distress about employment and education, as are expected with standard intervention approaches for justice-involved youth. Participants who show improvement in emotion regulation across engagement (approximately half the cohort), were found to have significant improvements in distress related to relationship and family functioning and self-care, and decreased substance use, along with other outcomes compared to those participants with less improvement in emotion regulation. Furthermore, improvement in different aspects of emotion regulation were associated with improved relationships, life distress, substance use, and improved prosocial thinking. Conclusions: Together, these data suggest that adding mental health support and skills training, such as with trauma-informed CBT models, to programs for justice-involved youth may lead to significant improvements in functioning, quality of life, and mental health outcomes.

Correlates of quality of life and functional disability in individuals with body dysmorphic disorder.

OBJECTIVE: Body dysmorphic disorder (BDD) is a chronic mental illness characterized by low quality of life and functional disability across multiple domains. Despite the clinical importance of understanding impairment in BDD, there has been little research examining the factors that contribute to these constructs. The present study was designed to examine sociodemographic and clinical correlates of quality of life and disability (work, social, and family) in a sample of individuals with moderately severe BDD symptoms. METHOD: Participants completed an internet survey with questions about demographics, BDD phenomenology, treatment, and impairment. Only participants who completed all study measures and received a score≥16 on the 10-item Yale-Brown Obsessive Compulsive Scale, Modified for BDD (BDD-YBOCS), indicating the presence of clinical BDD symptoms, were included in the analysis (n=256). Multivariate regression with backwards variable selection was used to identify significant predictors of quality of life and functional disability, assessed with the Quality of Life Enjoyment and Satisfaction Scale-Short Form (QLESQ-SF) and the Sheehan Disability Scale (SDS), respectively. RESULTS: BDD symptom severity was inversely associated with quality of life and directly associated with disability in all domains. After controlling statistically for BDD symptom severity, sociodemographic and clinical factors such as age, gender, ethnicity, marital status, insurance, body parts of concern, depression symptoms, and anxiety symptoms were significantly associated with impairment. CONCLUSION: Results suggest a multidimensional nature of quality of life and functional disability and underscore the importance of developing holistic treatment strategies to address impairment in BDD.

Comparative prevalence, correlates of impairment, and service utilization for eating disorders across US ethnic groups: Implications for reducing ethnic disparities in health care access for eating disorders.

OBJECTIVE: The study compared the prevalence, correlates of functional impairment, and service utilization for eating disorders across Latinos, Asians, and African Americans living in the United States to non-Latino Whites. METHOD: Pooled data from the NIMH Collaborative Psychiatric Epidemiological Studies (CPES;NIMH, 2007) were used. RESULTS: The prevalence of anorexia nervosa (AN) and binge-eating disorder (BED) were similar across all groups examined, but bulimia nervosa (BN) was more prevalent among Latinos and African Americans than non-Latino Whites. Despite similar prevalence of BED among ethnic groups examined, lifetime prevalence of any binge eating (ABE) was greater among each of the ethnic minority groups in comparison to non-Latino Whites. Lifetime prevalence of mental health service utilization was lower among ethnic minority groups studied than for non-Latino Whites for respondents with a lifetime history of any eating disorder. DISCUSSION: These findings suggest the need for clinician training and health policy interventions to achieve optimal and equitable care for eating disorders across all ethnic groups in the United States.

Barriers to treatment and service utilization in an internet sample of individuals with obsessive-compulsive symptoms.

BACKGROUND: Despite the increasing dissemination of treatment for Obsessive-Compulsive Disorder (OCD) in the past decade, the majority of individuals with OCD are not receiving appropriate treatment. This study examined rates of treatment utilization and barriers to treatment in an internet sample of individuals with self-reported OCD. METHODS: One hundred and seventy-five participants completed an online survey examining OCD symptoms, psychosocial measures, barriers to treatment, and treatment utilization. RESULTS: Sixty percent of the sample reported receiving treatment for their OCD symptoms. The majority of participants who sought pharmacotherapy received SSRIs, whereas the majority who sought psychotherapeutic treatment received "talk therapy." The cost of treatment, lack of insurance coverage, shame, and doubt that treatment would be effective were the most commonly endorsed barriers to treatment among the sample. CONCLUSIONS: Findings demonstrated relatively low treatment utilization rates among the sample, with many participants receiving treatments other than the gold-standard medication and psychotherapy treatments (i.e. SSRIs and cognitive behavioral therapy, respectively). Furthermore, a large portion of the sample endorsed many barriers to treatment seeking, such as logistic and financial barriers; stigma, shame, and discrimination barriers; and treatment perception and satisfaction barriers. This study highlights the need for more effective treatment dissemination in OCD.