Effect of Computer-Assisted Cognitive Behavior Therapy vs Usual Care on Depression Among Adults in Primary Care: A Randomized Clinical Trial.

Importance: Depression is a common disorder that may go untreated or receive suboptimal care in primary care settings. Computer-assisted cognitive behavior therapy (CCBT) has been proposed as a method for improving access to effective psychotherapy, reducing cost, and increasing the convenience and efficiency of treatment for depression. Objectives: To evaluate whether clinician-supported CCBT is more effective than treatment as usual (TAU) in primary care patients with depression and to examine the feasibility and implementation of CCBT in a primary care population with substantial numbers of patients with low income, limited internet access, and low levels of educational attainment. Design, Setting, and Participants: This randomized clinical trial included adult primary care patients from clinical practices at the University of Louisville who scored 10 or greater on the Patient Health Questionnaire-9 (PHQ-9) and were randomly assigned to CCBT or TAU for 12 weeks of active treatment. Follow-up assessments were conducted 3 and 6 months after treatment completion. Enrollment occurred from June 24, 2016, to May 13, 2019. The last follow-up assessment was conducted on January 30, 2020. Interventions: CCBT included use of the 9-lesson computer program Good Days Ahead, along with as many as 12 weekly telephonic support sessions of approximately 20 minutes with a master's level therapist, in addition to TAU, which consisted of the standard clinical management procedures at the primary care sites. TAU was uncontrolled, but use of antidepressants and psychotherapy other than CCBT was recorded. Main Outcomes and Measures: The primary outcome measure (PHQ-9) and secondary outcome measures (Automatic Thoughts Questionnaire for negative cognitions, Generalized Anxiety Disorder-7, and the Satisfaction with Life Scale for quality of life) were administered at baseline, 12 weeks, and 3 and 6 months after treatment completion. Satisfaction with treatment was assessed with the Client Satisfaction Questionnaire-8. Results: The sample of 175 patients was predominately female (147 of 174 [84.5%]) and had a high proportion of individuals who identified as racial and ethnic minority groups (African American, 44 of 162 patients who reported [27.2%]; American Indian or Alaska Native, 2 [1.2%]; Hispanic, 4 [2.5%]; multiracial, 14 [8.6%]). An annual income of less than $30 000 was reported by 88 of 143 patients (61.5%). Overall, 95 patients (54.3%) were randomly assigned to CCBT and 80 (45.7%) to TAU. Dropout rates were 22.1% for CCBT (21 patients) and 30.0% for TAU (24 patients). An intent-to-treat analysis found that CCBT led to significantly greater improvement in PHQ-9 scores than TAU at posttreatment (mean difference, -2.5; 95% CI, -4.5 to -0.8; P = .005) and 3 month (mean difference, -2.3; 95% CI, -4.5 to -0.8; P = .006) and 6 month (mean difference, -3.2; 95% CI, -4.5 to -0.8; P = .007) follow-up points. Posttreatment response and remission rates were also significantly higher for CCBT (response, 58.4% [95% CI, 46.4-70.4%]; remission, 27.3% [95% CI, 16.4%-38.2%]) than TAU (response, 33.1% [95% CI, 20.7%-45.5%]; remission, 12.0% [95% CI, 3.3%- 20.7%]). Conclusions and Relevance: In this randomized clinical trial, CCBT was found to have significantly greater effects on depressive symptoms than TAU in primary care patients with depression. Because the study population included people with lower income and lack of internet access who typically have been underrepresented or not included in earlier investigations of CCBT, results suggest that this form of treatment can be acceptable and useful in diverse primary care settings. Additional studies with larger samples are needed to address implementation procedures that could enhance the effectiveness of CCBT and to examine potential factors associated with treatment outcome. Trial Registration: ClinicalTrials.gov Identifier: NCT02700009.

Screening for trauma and behavioral health needs in child welfare: Practice implications for promoting placement stability.

BACKGROUND: Although the child welfare field has initiated efforts to use standardized screening for trauma and behavioral health needs, research has rarely examined whether these screenings have influenced permanency outcomes. OBJECTIVE: Using data from three states' federal demonstration projects, we examined whether receipt of trauma and behavioral health screening and results of screening were associated with placement stability (i.e., fewer placements). Our inquiry focused on whether similar patterns of statistical associations would be observed in three distinct state settings. PARTICIPANTS AND SETTING: Samples comprised children in out-of-home care in three states newly implementing trauma and behavioral health screening. The states included a South Central state, New England state, and a Central Midwestern state. RESULTS: In all three states, findings showed children who received screening had a higher number of placements (i.e., placement instability). Likewise, all three states found that children whose screening results indicated greater need, such as higher number of trauma symptoms or lower behavioral health functioning, were more likely to experience a higher number of placements (i.e., placement instability). CONCLUSION: Despite differences in screening tools and state-specific approaches, findings suggest that early screenings may provide important information that could be used to identify children's needs, make appropriate service referrals, establish well-matched placements, and support resource parents and birth parents toward better permanency outcomes. Regardless of potential benefits of early screening, it may be underutilized in the field. Future research is needed to replicate these findings and continue to build an evidence base for trauma and behavioral health screening.

Dissemination of computer-assisted cognitive-behavior therapy for depression in primary care.

Computer-assisted cognitive-behavior therapy (CCBT) for depression in primary care will be evaluated in a trial with 240 patients randomly assigned to CCBT or treatment as usual (TAU). The study will disseminate a therapy method found to be effective in psychiatric settings into primary care - a setting in which there have been significant problems in the delivery of adequate, evidence-based treatment for depression. The study will include a high percentage of disadvantaged (low-income) patients - a population that has been largely ignored in previous research in CCBT. There have been no previous studies of CCBT for depression in primary care that have enrolled large numbers of disadvantaged patients. The form of CCBT used in this study is designed to increase access to effective therapy, provide a cost-effective method, and be a sustainable model for wide-spread use in primary care. In order to deliver therapy in a practical manner that can be replicated in other primary care practices, patients with significant symptoms of depression will receive treatment with an empirically supported computer program that builds cognitive-behavior therapy skills. Support for CCBT will be provided by telephone and/or e-mail contact with a care coordinator (CC) instead of face-to-face treatment with a cognitive-behavior therapist. Outcome will be assessed by measuring CCBT completion rate, comprehension of CBT concepts, and satisfaction with treatment, in addition to ratings of depressive symptoms, negative thoughts, and quality of life. The cost-effectiveness analysis and exploration of possible predictors of outcome should help clinicians, health care organizations, and others plan further dissemination of CCBT in primary care.

Changes in Couple Relationship Dynamics among Low-Income Parents in a Relationship Education Program Are Associated with Decreases in Their Children's Mental Health Symptoms.

Witnessing intimate partner violence (IPV) among parents negatively impacts millions of children in the United States each year. Low-income families are disproportionately affected by IPV compared to middle- and high-income individuals, and are beginning to be the focus of IPV secondary prevention interventions, including relationship education programs. Despite these developments, few studies have examined changes in psychosocial functioning among children of parents participating in relationship education programs. The current study examined the extent to which changes in specific couple dynamics among individuals from low-income backgrounds participating in a couple relationship education program, Within My Reach, were associated with changes in child mental health symptoms. A second purpose of this paper is to examine whether changes in parent⁻child relationship quality mediates the association between changes in couple dynamics and changes in child mental health difficulties. Participants (n = 347) were parents who participated in Within My Reach as part of programming offered at a large community agency. Decreases in negative couple conflict behaviors, including conflict engagement, withdrawal and compliance, over the course of the program were linked to decreases in child mental health difficulties. In addition, increases in parent⁻child relationship quality partially mediated the associations between decreases in compliance, as well as increase in overall couple relationship quality, and decreases in child symptoms. Community-based couple relationship education programs for low-income families can potentially have multiple positive impacts throughout the family system, including for children.

Members' attendance rates and outcomes of relationship education groups: A consensus-dispersion analysis.

Relationship education programs (REPs) are an effective way to enhance relationship communication, prevent relational distress, and increase relationship quality. Most REPs are delivered in a group format; however, there is little known about the influence of group processes on outcomes for these programs, such as group members' attendance. Therefore, the current study applied a dispersion-consensus model to test the impact of attendance at the member and group levels on group members' REP outcomes. In a sample of 558 lower income, primarily African American participants, we examined whether individual and group attendance rates influenced posttreatment communication patterns and relationship quality. Results indicated that an individual group member's attendance was significantly and positively related to their posttreatment relationship quality, although this relationship is complex. Specifically, this relationship was stronger in groups with higher levels of attendance as well as groups with more attendance variability. In addition, results indicated that group members reported better posttreatment relationship quality in groups with less variability in members' attendance. However, we found a significant interaction between attendance consensus and variability, and an individual group member's posttreatment relationship quality, suggesting that group members report higher levels of relationship quality in groups where the attendance of the group as a whole is lower yet more consistent. No significant relationships were found for group member's posttreatment communication patterns. Our findings suggest that the rate and variability in the group's attendance, as well as an individual group member's own attendance significantly impacts their posttreatment relationship quality in complex ways. (PsycINFO Database Record

Impact of Two Adolescent Pregnancy Prevention Interventions on Risky Sexual Behavior: A Three-Arm Cluster Randomized Control Trial.

OBJECTIVES: To test the efficacy of Reducing the Risk (RTR) and Love Notes (LN) on reducing risky sexual behavior among youths yet to experience or cause a pregnancy. METHODS: The four dependent variables were ever had sex, condom use, birth control use, and number of sexual partners at 3- and 6-month follow-up in a 3-arm cluster randomized controlled trial of 1448 impoverished youths, aged 14 to 19 years, in 23 community-based organizations in Louisville, Kentucky, from September 2011 through March 2014. RESULTS: At 3 and 6 months, compared with the control condition, youths in RTR reported fewer sexual partners and greater use of birth control. At 6 months, LN participants reported greater use of birth control and condoms, fewer sexual partners, and were less likely to have ever had sex compared with the control condition. CONCLUSIONS: We provided additional evidence for the continued efficacy of RTR and the first rigorous study of LN, which embeds sex education into a larger curriculum on healthy relationships and violence prevention.

Alliance and group cohesion in relationship education.

Relationship education programs have been shown as an effective way to increase relationship functioning. There is less known about how process factors, such as alliance with the leader or group dynamics, affect outcomes in these interventions. We examined group cohesion and alliance with the leader in a relationship education program tailored for individuals. Specifically, we examined whether participants' ratings (n = 126) of the group cohesion and alliance with the leader were associated with changes in relationship adjustment, relationship confidence, and communication quality from pre- to postintervention. The results demonstrated that participants' perceptions of the cohesion among the members in their relationship education group, but not the leader-participant alliance, made a significant contribution to the changes in participants' relationship functioning. These results suggest that the group dynamics among the members in the group are important ingredients in relationship education. Implications for relationship programs are provided.

Exploring attitudes regarding smokeless tobacco products for risk reduction.

Utilizing qualitative data analysis, this study focused on the attitudes, knowledge, and beliefs relating to smokeless tobacco (ST) as a reduced-risk cigarette substitute for smokers among focus groups from the general public and from the health profession. It revealed that there is a lack of awareness and understanding of ST products, which has a significant impact on overall perception of these products as acceptable substitutes. Regulatory actions regarding tobacco by the U.S. Food and Drug Administration should enhance consumers' access to accurate information about nicotine addiction and tobacco use.

The impact of the within my reach relationship training on relationship skills and outcomes for low-income individuals.

A federal grant was awarded to provide the Within My Reach healthy relationships curriculum to low-income, at-risk individuals involved with various social service agencies. The effectiveness of this curriculum was evaluated for 202 participants through measures of training and relationship outcomes pre-, immediately post- and 6 months posttraining. Participants experienced high levels of training satisfaction; significant increases in knowledge, communication/conflict resolution skills, and relationship quality; as well as a trend in the reduction of relationship violence. An important implication of this research is that MFTs may broaden their service delivery to at-risk individuals by collaborating with community agencies to adapt established relationship enhancement programs, evidence-based tools, and principles that complement traditional couples therapy.

The impact of the Solution Based Casework (SBC) practice model on federal outcomes in public child welfare.

OBJECTIVE: To test the effects of the Solution-Based Casework practice model on federal outcomes of safety, permanency and well-being. The Solution-Based Casework model combines family development theory, solution-focused skills and relapse prevention for the casework process in child protection. METHOD: 4,559 public child welfare cases were reviewed through a CQI case review process. RESULTS: This study found that cases with high levels of fidelity to the model demonstrated significantly better outcomes in the areas of child safety, permanency and well-being and exceeded federal standards, while cases with low fidelity to the model failed to meet federal standards. CONCLUSION: Components of the Solution-Based Casework were significant predictors of these federal outcomes and accounted for variance in these outcomes better than any other casework process factors.

Recruiting and retaining child welfare workers: is preparing social work students enough for sustained commitment to the field?

Graduates of specialized BSW child welfare education programs are more likely to be retained after two years of service in the agency, but many leave at the four year mark. Two studies explored possible reasons for departure at this time. The first study found that graduates of specialized child welfare programs were significantly more likely to engage in best practices in nine areas than workers from other fields. Thus, frustration with practice skill was ruled out as a cause. The second qualitative study found that poor supervision, lack of coworker support, and organizational stress among other variables prompted these high-functioning workers to leave the agency. Suggestions for innovative interventions to enhance retention at this critical juncture are included.

The effects of training reinforcement on training transfer in child welfare.

The purpose of this research was to compare the impact of different training methods on training transfer. Child welfare workers were assigned to one of three groups: classroom training only, classroom training plus reinforcement, and no training. The effect of these different training approaches on the transfer of assessment and case planning skills from the training was examined through a review of 120 child welfare case records. Results indicated that providing both training and reinforcement yielded a higher level of transfer than training alone or no training.

Expedited permanency planning: evaluation of the Kentucky Adoptions Opportunities Project.

This article presents the evaluation findings of a Kentucky Adoptions Opportunities Project (KAOP), a three-year project funded by the U.S. Department of Health and Human Services, Administration on Children, Youth and Families, Children's Bureau. The primary goal of the KAOP was implementation of three permanency planning activities: (1) risk assessment/concurrent planning, (2) one child/one legal voice, and (3) early placement in kinship or foster/adoptive homes. These activities were designed to expedite a permanency placement decision within 12 months for high-risk children. The evaluation of 124 high-risk children in the KAOP revealed that the majority of children had one or both parents coping with multiple risk factors, including mental illness, substance abuse, mental retardation, or family violence. The major barriers to permanency are discussed, as well as the policy and practice implications in the context of Adoption and Safe Families Act of 1997.