Adolescent engagement in a stepped care, transdiagnostic mental health intervention delivered in Indian schools.

Given the relationship between poor engagement and worse treatment outcomes, improving engagement has been the focus of attention in recent years. Engagement is a particular challenge among minoritized and otherwise challenged youth, such as those from socioeconomically disadvantaged groups, including youth in low- and middle-income countries (LMICs), where they face lower levels of access to resources, including mental health treatment. The present study describes engagement challenges that arose in an uncontrolled pre-post evaluation of a school-based, modular, multi-problem, stepped-care intervention delivered in urban Indian communities. Specifically, the study aimed to (1) characterize barriers and facilitators of youth treatment engagement; and (2) evaluate treatment acceptability and fit of treatment from the youth perspective. Youth participants completed semi-structured interviews, which were transcribed and coded using thematic analysis. Participants described numerous facilitators to engagement (e.g., positive therapeutic relationship) and reported high overall satisfaction with the intervention, while also identifying barriers to engagement (e.g., concerns about confidentiality) and offering suggestions to increase fit and acceptability (e.g., more visually appealing treatment materials). Findings highlight ways in which engagement can be enhanced and implementation supports improved to maximize treatment effectiveness among minoritized and disadvantaged youth in LMICs. Supplementary Information: The online version contains supplementary material available at 10.1007/s44202-024-00154-1.

Mental health and psychosocial interventions integrating sexual and reproductive rights and health, and HIV care and prevention for adolescents and young people (10-24 years) in sub-Saharan Africa: a systematic scoping review.

Background: Interventions targeting combined sexual and reproductive health, Human Immunodeficiency Virus (HIV) management and mental health care in sub-Saharan Africa (SSA) are few. There is a need to address common determinants of poor mental, psychosocial and sexual and reproductive health and rights (SRHR) through multimodal and multipronged interventions for adolescents. The main objective of this study was to identify whether and how interventions targeting adolescent SRHR and HIV with a focus on pregnant and parenting adolescents in SSA include mental health components and how these components and their outcomes have been reported in the literature. Methods: We carried out a two process scoping review approach between 01.04.2021 and 23.08.2022. In the first stage, we searched the PubMed database to identify studies focusing on adolescents and young people aged 10 to 24 from 2001 to 2021. We identified studies focusing on HIV and SRHR that had mental health and psychosocial aspects to the interventions. Our search yielded 7025 studies. Of these 38 were eligible based on our screening criteria that covered interventions, and on further scrutiny, using PracticeWise, an established coding system, we identified select problems and practices to provide a more granular assessment of how interventions developed for this context mapped on to specific problems. At this second stage process, we selected 27 studies for inclusion as actual interventional designs for further systematic scoping of their findings and we used the Joanna Briggs Quality Appraisal checklist to rate these studies. This review was registered within the International Prospective Register of Systematic Reviews (PROSPERO), number CRD42021234627. Findings: Our first set of findings is that when coding problems and solutions, mental health concerns were the least common category of problems targeted in these SRHR/HIV interventions; nevertheless, psychoeducation and cognitive behavioral strategies such as improved communication, assertiveness training, and informational support were offered widely. Of the 27 interventional studies included in the final review, 17 RCTs, 7 open trials, and 3 mixed designs, represented nine countries of the 46 countries in SSA. Intervention types included peer, community, family, digital, and mixed modality interventions. Eight interventions focused on caregivers and youth. Social or community ecology associated problems (being an orphan, sexual abuse, homelessness, negative cultural norms) were the most common risk factors and were more frequent than medical issues associated with HIV exposure. Our findings highlight the relevance and centrality of social issues related to adolescent mental and physical health along with the need to strengthen multimodal interventions along the lines of problems we have identified in our review. Interpretation: Combined interventions jointly addressing adolescent SRHR, HIV, and mental health have been relatively understudied, despite evidence that adverse social and community factors are rampant in this population. Funding: MK was funded by Fogarty International CenterK43 TW010716-05 and lead the initiative.

Observed Engagement in Community Implemented Evidence-Based Practices for Children and Adolescents: Implications for Practice Delivery.

OBJECTIVE: This observational study characterizes youth and caregiver behaviors that may pose challenges to engagement within a system-driven implementation of multiple evidence-based practices (EBPs). We examined links between Engagement Challenges and therapist EBP implementation outcomes. METHOD: Community therapists (N = 102) provided audio recordings of EBP sessions (N = 666) for youth (N = 267; 71.54%, Latinx; 51.69%, female; Mage = 9.85, Range: 1-18). Observers rated the extent to which youth and/or caregivers engaged in the following behaviors: Caregiver and/or Youth Expressed Concerns about interventions, and Youth Disruptive Behaviors. Multilevel modeling was used to identify predictors of observable Engagement Challenges, and examine associations between Engagement Challenges, and therapist-reported ability to deliver planned activities, and observer-rated extensiveness of EBP strategy delivery. RESULTS: At least one Engagement Challenge was observed in 43.99% of sessions. Youth Engagement Challenges were not associated with outcomes. Caregiver Expressed Concerns were negatively associated with therapist-reported ability to carry out planned session activities (B = -.21, 95% CI[-.39-(-.02)], p < .05). However, Caregiver Expressed Concerns were positively associated with extensiveness of EBP Content strategy delivery (B = .08, 95% CI[.01-.15], p < .05). CONCLUSIONS: Results suggest that Youth Engagement Challenges have little observed impact on EBP delivery. In contrast, although therapists perceive that Caregiver Expressed Concerns derail their planned activities, Caregiver Expressed Concerns are associated with more extensive delivery of content about therapeutic interventions. Community therapists' implementation of EBPs appear unaffected by common youth in-session behavioral challenges, but future research is needed to clarify whether caregivers' concerns about interventions prompt, or are prompted by, more intensive therapist EBP content instruction.

Supporting the implementation of written exposure therapy for posttraumatic stress disorder in an obstetrics-substance use disorder clinic in the Northeastern United States.

Pregnant people with comorbid posttraumatic stress disorder (PTSD) and substance use disorder (SUD) constitute a highly vulnerable population. PTSD and SUD confer risks to both the pregnant person and the fetus, including a host of physical and mental health consequences. When PTSD and SUD co-occur, potential negative impacts are amplified, and the symptoms of each may exacerbate and maintain the other. Pregnancy often increases engagement in the healthcare system, presenting a unique and critical opportunity to provide PTSD and SUD treatment to birthing people motivated to mitigate risks of losing custody of their children. This paper presents implementation process outcomes of Written Exposure Therapy (WET), a brief, scalable, and sustainable evidence-based PTSD treatment delivered to pregnant persons receiving care in an integrated obstetrical-addiction recovery program at Boston Medical Center. Trial participants (N = 18) were mostly White, non-Hispanic (61.1%), not currently working (77.8%), had a high school or lower level of education (55.5%), had an annual household income less than $35,000 (94.4%), and were living in a substance use residential program (55.6%). We examined intervention feasibility, acceptability, appropriateness, adoption; barriers and facilitators to implementation; and feedback on supporting uptake and sustainability of the intervention using coded qualitative sources (consultation field notes [N = 47] and semi-structured interviews [N = 5]) from providers involved in trial planning and treatment delivery. Results reflected high acceptability, appropriateness, and adoption of WET. Participants described system-, provider-, and patient-level barriers to implementation, offered suggestions to enhance uptake, but did not raise concerns about core components of the intervention. Findings suggest that WET is an appropriate and acceptable PTSD treatment for this difficult-to-reach, complex population, and has the potential to positively impact pregnant persons and their children.

A qualitative analysis of collaborative efforts to build a school-based intervention for multiple common adolescent mental health difficulties in India.

Introduction: In low- and middle-income countries (LMICs), the gap between need for mental health (MH) treatment and access to services is stark, particularly among children and adolescents. In service of addressing this treatment gap, the current study provides an in-depth illustration of later-stage collaborative design of a school-based, transdiagnostic MH intervention in New Delhi and Goa, India, using a combination of contextual insights from local stakeholders and knowledge derived from the global evidence base. Methods: Using an inductive-deductive approach to qualitative thematic analysis, we examined coded data from qualitative sources related to experiences of developing and implementing an intervention prototype. These sources included notes from meetings attended by treatment development team members and providers, written feedback on protocol materials (e.g., provider manual, student handouts), field notes reflecting researcher observations, and minutes from weekly clinical supervision meetings. Results: Results revealed that codes involving cultural/contextual considerations, protocol material and content, and intervention complexity arose consistently throughout treatment development and across document types, illustrating their central role in finalizing protocol design. Discussion: These findings have implications for the future of mental health treatment development and implementation globally.

Refugee mental health: Culturally relevant considerations.

In recent years, multiple global crises have contributed to increasing human displacement. Currently, there are approximately 84 million displaced people around the world. Many suffer from mental health problems. However, the mental health service delivery system is not fully prepared to meet the complex needs of refugees. Refugees experience multiple barriers, both individual and systemic, to accessing and engaging in mental health treatment. The following article provides an overview of some of the challenges faced by refugees worldwide and avenues forward. The authors also examine contextual factors that impact refugee resettlement and discuss barriers to culturally responsive, trauma-informed, and ethical care. Finally, the authors review advocacy efforts and discuss future directions to improve refugee mental health care delivery.

Identified needs of peripartum adolescents in Sub-Saharan Africa from 2013 to 2021: a mapping of domains for strengthening psychosocial interventions.

Adolescent pregnancy and early motherhood pose significant socioeconomic and health risks in Sub-Saharan Africa, leading to considerable morbidity and mortality. To learn more about the needs of this population, we reviewed 24 articles featuring 21 samples covering 12,490 adolescents from 14 countries. Our coding revealed that adolescent mothers were studied more (85.7% of samples) than pregnant adolescents (61.9%). We summarized needs as per six categories. Resource needs were most prevalent, reported by 100% of samples, followed by ecology (85.7%), mental health (76.2%), medical (61.9%), other (61.9%), and education (33.3%). The most frequently reported resource needs were low income and unemployment. Low social support, low family functioning, and exposure to negative cultural norms were ecological needs prevalent in most samples. Among mental health concerns, depression was the most commonly reported problem, whereas other problems, such as anxiety, substance use, and suicidality, were reported much less frequently. HIV-positive status was the most frequently reported medical concern. Intervention developers should consider the range of challenges when designing psychosocial services for this population.

A pilot study to evaluate feasibility and acceptability of training mental health workers in India to select case-specific intervention procedures within a dynamic modular treatment designed for a low-resource setting.

RATIONALE, AIMS AND OBJECTIVES: A key consideration in designing scalable solutions for improving global mental health involves balancing the need for interventions to be uncomplicated for mental health workers (MHWs) and the need for the intervention to be widely applicable to many clients. Often these needs are in competition, since interventions are routinely simplified by removing procedures or reducing their dynamic responsivity, which in turn lowers their overall utility in serving large, clinically diverse populations. The principal aim of this pilot study involved evaluating the feasibility and acceptability of a brief strategy designed to delegate problem classification and practice selection to MHWs operating within a flexible, modular, cognitive behavioural protocol. A secondary aim involved gathering data on which to base a hypothesis regarding the potential effectiveness of this strategy. METHOD: Within an open trial, an educationally diverse sample of local MHWs in India (N = 18) reviewed fictional case vignettes, classified mental health problems, and then selected practices before and after a two-hour training that included a one-page decision-making resource. Feasibility was measured by assessing the integrity of the study protocol and training, the measurement and administration of questionnaires as well as study recruitment and completion. Acceptability of the intervention was measured by MHW-perceived performance, ease of use, value, importance, and intention for continued use. Decision-making accuracy was assessed by comparing MHWs' clinical decisions with criteria established through consensus among psychologists with expertise in modular protocols. RESULTS: Results suggested high feasibility and acceptability on all metrics. Secondary analysis revealed that MHW's decision-making accuracy and confidence also significantly improved, providing a basis for the hypothesis that this brief approach is useful for building MHW capacity in low-resource settings. CONCLUSION: Overall these findings provide initial support for these methods and potential training outcomes to test within a larger, randomized controlled trial.

A Mixed-Method Analysis on the Impacts of a System-Driven Implementation of Multiple Child Evidence-Based Practices on Community Mental Health Providers.

Initiatives to scale up evidence-based practices (EBPs) in routine care are likely to have myriad impacts on community providers, but these impacts have not yet been examined in depth. This is especially true within the context of simultaneous implementation of multiple evidence-based practices. The aim of this study was to characterize the multifaceted impacts on community mental health therapists within a system-driven implementation of multiple EBPs for youth and families. Semistructured interview and survey data were gathered from 60 therapists at 11 agencies contracted with the Los Angeles County Department of Mental Health to deliver EBPs within the Prevention and Early Intervention initiative. Therapists' accounts of impacts varied, and were either predominately negative, predominantly positive, or mixed-valence. Mixed-methods analyses using Kruskal-Wallis tests showed therapist valence groups varied on mean levels of self-reported burnout on surveys. Themes from qualitative data revealed several favorable (e.g., increased EBP knowledge, structure) and unfavorable (e.g., distress, feeling constrained by EBPs) impacts of county-contracted EBP implementation. These findings inform the development and implementation of future system-driven EBP initiatives that consider therapist perspective to optimize positive impacts and minimize negative impacts on therapists.

Design process and protocol description for a multi-problem mental health intervention within a stepped care approach for adolescents in India.

This paper documents the collaborative design of a mental health intervention for adolescents in India with anxiety, depression, or anger-related concerns. The process was characterized by three phases of formative activities: (1) an intensive review of the service context, (2) selection of an overall design strategy (e.g., whether to choose existing evidence-based treatments or build new treatments in context), and (3) a period of prototyping, testing, and refining. Each phase resulted in specific outputs, which were, respectively, (1) a detailed articulation of values and preferences (setting expectations for what the ideal protocol should be), (2) a set of build parameters representing a blueprint that managed strategic compromises for this context, and (3) a working protocol. We outline the steps of this design process, summarize data from an open-trial clinical case series, and illustrate the resulting working protocol, which will be tested in a future larger trial. We conclude with insights and observations likely to be relevant to protocol design activity in a variety of contexts, most particularly those in low-and-middle-income countries such as India.

Using relevance mapping methodology to design an adolescent mental health intervention in India.

BACKGROUND: Adolescents in low and middle-income countries experience pronounced mental health needs in contexts where infrastructure and resources are scarce. While evidence-based treatment are readily available, they may not fit the unique needs of certain contexts. OBJECTIVE: This manuscript illustrates the systematic process of applying 'relevance mapping' methodology to leverage the youth mental health evidence base to identify candidate practices for inclusion in the development of a contextually appropriate psychological treatment protocol for common adolescent mental health problems in India. METHODS: The practice identification was informed by two datasets obtained from adolescent samples in India. The first was an epidemiological dataset from a large community sample in Goa (N = 2,048); the second incorporated 'youth top problems' reported by service-seeking students presenting to school counsellors in Goa and Delhi (N = 78). Problems identified in each dataset were categorized using structured codes. Problem codes and youth demographics were then indexed against a database of hundreds of evidence-based psychological treatments and their associated clinical trials. This methodology revealed the most common practice elements (discrete therapeutic strategies) and their most efficient combinations with evidence of effectiveness matching the demographics and diagnostic category (anxiety, disruptive behaviors and depression) prevalent in the planned treatment population. RESULTS: For anxiety, the most common practice elements for this age group were exposure, cognitive coping, and psychoeducation. For disruptive behaviors, the most common practices were problem-solving, goal-setting, and rapport-building. For depression, cognitive coping, behavioral activation, and psychoeducation were the most common practice elements. CONCLUSION: These practice elements provided the treatment development team with a preliminary list of candidate content for the development of an intensive psychological treatment within a stepped care service model to address common adolescent mental health problems in schools in India.

Community Mental Health Professionals' Perceptions About Engaging Underserved Populations.

This study explored mental health professionals' perceptions about barriers and facilitators to engaging underserved populations. Responses were coded using an iterative thematic analysis based on grounded theory. Results revealed that many professionals endorsed barriers to engaging ethnic minorities and families receiving social services. Client-provider racial and linguistic matching, therapy processes and procedures (e.g., nonjudgmental stance), and implementation supports (e.g., supervision) were commonly nominated as engagement facilitators. Many professionals felt that an organizational culture focused on productivity is detrimental to client engagement. Findings shed light on professionals' perceived barriers to delivering high-quality care to underserved communities and illuminate potential engagement strategies.

Predictors of Burnout among Community Therapists in the Sustainment Phase of a System-Driven Implementation of Multiple Evidence-Based Practices in Children's Mental Health.

Burnout among community mental health (CMH) therapists has been associated with poorer therapist health, high agency turnover, poorer client outcomes, and compromised quality of care. Recent mandates to learn and implement multiple evidence-based practices (EBPs) within CMH settings are intended to improve the quality of community care, yet there is mixed evidence concerning the impacts on workforce burnout. The current study sought to identify correlates of therapist emotional exhaustion, a key aspect of burnout, during the sustainment phase of a system-driven implementation of multiple EBPs in children's mental health services. We hypothesized that high workload and unfavorable organizational climate would relate to therapist emotional exhaustion, but that positive experiences with EBPs adopted would relate to lower exhaustion. Although agency-level indices of organizational climate were unrelated to exhaustion, a multilevel model revealed that therapists' weekly work hours, caseload, and number of EBPs delivered were associated with increased emotional exhaustion. Additionally, activities associated with the EBP implementation efforts (e.g., hours spent in EBP-related activities, supervision or consultation, or outcome monitoring), were not associated with emotional exhaustion. Therapists' knowledge and confidence delivering EBPs and their positive perceptions of EBPs were protective against emotional exhaustion, but these perceptions did not buffer the risks associated with heavy workload. Findings point to implementation strategies to prevent burnout and associated turnover that compromise the returns on investments in EBP implementation.

Forty Years of Engagement Research in Children's Mental Health Services: Multidimensional Measurement and Practice Elements.

Poor engagement in child and adolescent mental health services is a significant public health concern. The purpose of this study was to synthesize the engagement literature using a multidimensional measurement framework to identify practice elements that are associated with improved engagement. We examined 50 randomized controlled trials of interventions targeting treatment engagement in youth mental health services published between 1974 and 2016. We utilized a multidimensional measurement framework that includes five engagement domains (i.e., Relationship, Expectancy, Attendance, Clarity, Homework [REACH]). We also used a distillation method (Chorpita & Daleiden, 2009; Chorpita, Daleiden, & Weisz, 2005) to identify specific practices common to interventions that were effective at increasing engagement within each REACH domain. Engagement was most frequently operationalized in intervention studies as Attendance. Individual practices distilled from effective interventions were successful when used with participants with diverse characteristics in a wide variety of contexts. Importantly, we found unique practice patterns associated with outcomes from each REACH domain. Findings suggest that practices such as assessment, psychoeducation, accessibility promotion, barriers to treatment, and goal setting might be used with all youth and families to promote engagement and that other practices could be introduced on an as-needed basis to target specific engagement domains (e.g., modeling to promote Clarity about therapy; therapist monitoring to promote Homework/participation). A substantial evidence base demonstrates that engagement can be improved through specific interventions, and findings highlight opportunities to advance the field's understanding of engagement through multidimensional measurement in future studies.

Children and adolescents with Tourette's disorder in the USA versus Argentina: behavioral differences may reflect cultural factors.

To explore behavioral differences as possible cultural factors in presentation of psychiatric comorbidity in two clinically referred, consecutively ascertained samples of youth with Tourette's disorder (TD) from New York and Buenos Aires. Subjects were evaluated between 2002 and 2010 at the Tics and Tourette's Clinical and Research Program at the New York University Child Study Center in New York and the Interdisciplinary Center for Tourette's, Obsessive Compulsive Disorder (OCD) and Associated Disorders (CITTTA)/Institute of Cognitive Psychology (INECO) in Buenos Aires. Demographic, diagnostic, tic severity (Yale Global Tic Severity Scale; YGTSS), clinical (Child Behavior Check List-Parent version; CBCL), and global functioning (Global Assessment of Functioning; GAF) data were compared using descriptive statistics. The sample included 111 subjects ages 6-17 years, who met DSM-IV-TR diagnostic criteria for TD. Findings revealed that the BA sample (n = 35) was significantly older at initial evaluation at the tic specialty clinic, and had higher frequency of oppositional defiant disorder (ODD), mood and non-OCD anxiety disorders than the NY sample (n = 76). There were no differences in gender distribution, age at tic onset or TD diagnosis, tic severity, proportion with current diagnoses of OCD/OC behavior or attention deficit hyperactivity disorder (ADHD), CBCL internalizing, externalizing, or total problems scores, YGTSS scores, or GAF scores. The observed similarities in demographic features, clinical presentation, rates of ADHD and OCD/OCB, and global impairment may reflect similar phenomenology and illness-related characteristics of TD in these referred youth. Differences in age at initial specialty clinic evaluation and rates of ODD, mood and non-OCD anxiety disorders may need further exploration before they may be considered to reflect cultural factors. Because of these limitations (e.g. small sample size), these results can be regarded only as preliminary.