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.

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.

Knowing What To Do and When To Do It: Mental Health Professionals and the Evidence Base for Treatment Engagement.

Most mental health professionals encounter challenges to helping youth and families enroll and participate in mental health services. The empirical literature suggests that most engagement strategies are well-suited for certain types of engagement challenges. In this mixed-methods study, we examined whether mental health professionals reported using any solutions from the evidence base and, if so, the extent to which these procedures fit the engagement challenges they encountered. We surveyed all 244 mental health professionals working in a large urban school district about their experiences engaging youth and families in services. We coded professionals' written responses to open-ended questions about the challenges they encountered engaging youth and families in services, along with solutions they used to address these challenges. Most reported engagement challenges (83.3%) had a corresponding solution in the evidence base. Most reported solutions (86.5%) were practices found in the evidence base, yet most practices from the evidence base were infrequently nominated by professionals. Moreover, only 38.5% of professionals reported at least one solution that fit at least one of their challenges. In general, professionals reported using a narrow subset of engagement strategies from the literature, which often did not fit the engagement problems encountered. These results highlight opportunities for developing and disseminating a framework that explicitly coordinates evidence-based solutions matched to specific engagement challenges to support provider selection and application of engagement procedures and ultimately enhance youth and family engagement in services.

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.

Common Elements of Childhood Universal Mental Health Programming.

Despite the availability of multiple mental health prevention and promotion programs for children, challenges related to their dissemination limit their reach and impact. This review identifies the most common practice elements of effective childhood universal mental health programming for children ages 3-11, based on a structured interpretation and coding of program manuals and descriptions in peer-reviewed articles. Across a range of program goals and targeted outcomes, psychoeducation and problem solving emerged as the most common practice elements, followed by social skills training, insight building, and communication skills. These skills were largely taught via role-plays and modeling. Synthesizing what we know from the universal mental health programming literature has potential to facilitate dissemination of information to inform the development, adaptation or adoption of programs for children.

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.

Decision-Making in Mental Health Care: Measuring Provider and Supervisor Use of Evidence.

Use of evidence to inform clinical decisions has been shown to improve the quality and effectiveness of services. This study piloted an observational coding system for understanding providers and supervisors' use of evidence in their clinical decision-making. The Action Cycle and Use of Evidence Behavioral Observation Coding System (ACE-BOCS) is based on Graham et al. (Contin Educ Health Prof 26:13-24, 2006) conceptual framework for knowledge management, which articulates a sequence relevant to integrating evidence into decisions and actions, including identifying and selecting a problem and choosing, planning, and rehearsing a solution or action. Using the ACE-BOCS, two coders rated the extensiveness with which evidence was used to inform decisions made in clinical supervision sessions. In these clinical supervision sessions, supervisor-provider dyads discussed cases (N = 30; age range 8-19 years; 80% Latino/a or Hispanic ethnicity) that were identified as potentially being at risk for low treatment engagement in school mental health services. Results indicated that the ACE-BOCS can reliably and validly measure use of evidence and distinguish between strategic and indiscriminate use of evidence. The ACE-BOCS has value and utility for studying use of evidence, as it incorporates multiple actions related to service delivery and has the potential to be adapted for other aspects of mental healthcare decision-making beyond clinical supervision, as well as decision making within fields outside of mental health.

A pilot study to examine the feasibility and acceptability of a coordinated intervention design to address treatment engagement challenges in school mental health services.

Treatment engagement is a significant challenge in school mental health services. Despite a growing evidence base on effective interventions for treatment engagement, attempts to address these challenges rarely leverage the available relevant research. To close this gap, this pilot study examined the feasibility, acceptability, and initial implementation outcomes of a coordinated knowledge system (CKS) designed to support the efforts of school mental health (SMH) professionals to address treatment engagement challenges. A sample of four supervisors and their supervisees (n = 17) with master's of social work degrees serving youth within an urban SMH program were randomly assigned to either (a) a CKS condition that offered a unified set of resources to structure decisions about treatment engagement or (b) a survey plus practice guidelines (SPG) condition, in which resources were provided without an explicit model for their coordinated use. Feasibility was assessed quantitatively, acceptability was assessed quantitatively and qualitatively, and initial implementation outcomes were evaluated using a behavioral observation coding system. Results provided strong support for the feasibility and acceptability of the study design, instrumentation, and interventions. It appears that the CKS can be feasibly implemented with good acceptability. Patterns of initial implementation strongly suggested that, relative to the SPG, the CKS supports identification of engagement problems as well as intervention selection and planning. Findings also identified modifications to study procedures that would be necessary in a future study. A larger trial using similar methodology and instrumentation could yield important findings about the effectiveness of the CKS in clinical practice and could articulate the mechanisms by which it operates.

A systematic review of prevention programs targeting depression, anxiety, and stress in university students.

BACKGROUND: Given the prevalence of anxiety, depression, and stress among university students, it is important to assess the effectiveness of prevention programs for these problems. Beyond examining effect sizes, applying a common elements approach can enhance our understanding of which practice elements are most frequently included in symptom-reducing programs. METHOD: This review examined effective (i.e., outcome-producing) prevention programs targeting depression, anxiety, and/or stress in university students. Programs could be delivered in a group-based, online/computer-delivered, or self-administered format and at the universal, selective, or indicated prevention level. RESULTS: The resulting sample of 62 articles covered 68 prevention programs for college, graduate, or professional students across 15 countries. Average effect sizes for programs were moderate (overall g = 0.65), regardless of delivery format or prevention level. The most common practice elements (overall and for programs producing large effects) were: psychoeducation (72%), relaxation (69%), and cognitive monitoring/restructuring (47%). Many programs were limited by: (a) symptom target-outcome mismatches, (b) disproportionately female samples, and (c) inconsistently reported adherence data. LIMITATIONS: Commonness of practice elements across outcome-producing interventions does not imply their extensiveness nor unique contribution to effectiveness. Coding was based on information in articles rather than manuals, and inter-rater reliability was moderate for some practice elements. CONCLUSION: The outcome-producing prevention programs in our sample had common practice elements and produced moderate reduction in symptoms overall. Future research of depression, anxiety, and stress prevention programs for university students can investigate practice elements' unique and combined impact on outcomes, further explore under-tested practice elements, and use findings to inform intervention design.

"Teaching Moments" in Psychotherapy: Addressing Emergent Life Events Using Strategies From a Modular Evidence-Based Treatment.

Emergent life events (ELEs) are unexpected, acute client stressors reported in psychotherapy sessions that are associated with reduced evidence-based treatment (EBT) integrity and client progress. As a potential solution, this study examined the extent to which ELEs could be appropriately addressed using existing EBT strategies. Participants were 34 low-income youth (ages 5-15, 50% male, 85% Latino) seen by 18 therapy providers in the modular EBT condition (MATCH) of a community effectiveness trial. MATCH experts rated descriptions of 75 ELEs from therapy sessions on how well they might be addressed clinically by any of MATCH's 33 strategies for youth anxiety, depression, trauma, or conduct problems (i.e., "addressability"). MATCH-expert ratings were compared with observationally coded provider responses to ELEs. Results revealed that when assuming the presence of youth and caregiver in session, two-thirds of ELEs were identified as fully addressable and nearly all ELEs (96%) were partially addressable. ELEs related to family issues were most common but least likely to be addressable. Problem Solving and Relaxation skills could address the greatest percentage (87%) of ELEs. The most common supplemental content not explicitly prescribed in MATCH, but identified as necessary to fully address ELEs, was "assessing and empathic listening." Provider responses were often incongruent with MATCH-expert raters regarding which strategies to use for which ELEs. In summary, most ELEs reported in a diverse community sample could be theoretically harnessed as "teaching moments" for skills within an existing, multi-problem EBT. However, providers may benefit from development of a structured resource to guide them in choosing the most effective response when these unexpected events arise.

Building Resilience After School for Early Adolescents in Urban Poverty: Open Trial of Leaders @ Play.

Leaders @ Play is a park after-school program for urban middle school youth designed to leverage recreational activities for social emotional learning. Mental health and park staff co-facilitated sports and games to teach and practice problem solving, emotion regulation, and effective communication. Additional practice occurred during multi-family groups and summer internships as junior camp counselors. We examined feasibility and promise via an open trial (n = 3 parks, 46 youth, 100 % African American, 100 % low-income, 59 % female, M = 13.09 years old). Improvements in social skills and reductions in problem behaviors lend support to after school programs as a space for mental health promotion.

Common elements of adolescent prevention programs: minimizing burden while maximizing reach.

A growing number of evidence-based youth prevention programs are available, but challenges related to dissemination and implementation limit their reach and impact. The current review identifies common elements across evidence-based prevention programs focused on the promotion of health-related outcomes in adolescents. We reviewed and coded descriptions of the programs for common practice and instructional elements. Problem-solving emerged as the most common practice element, followed by communication skills, and insight building. Psychoeducation, modeling, and role play emerged as the most common instructional elements. In light of significant comorbidity in poor outcomes for youth, and corresponding overlap in their underlying skills deficits, we propose that synthesizing the prevention literature using a common elements approach has the potential to yield novel information and inform prevention programming to minimize burden and maximize reach and impact for youth.