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

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

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

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

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

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

The Impact of COVID-19 on Brain Stimulation Therapy.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico.

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.

Objective coding of content and techniques in workplace-based supervision of an EBT in public mental health.

BACKGROUND: Workplace-based clinical supervision as an implementation strategy to support evidence-based treatment (EBT) in public mental health has received limited research attention. A commonly provided infrastructure support, it may offer a relatively cost-neutral implementation strategy for organizations. However, research has not objectively examined workplace-based supervision of EBT and specifically how it might differ from EBT supervision provided in efficacy and effectiveness trials. METHODS: Data come from a descriptive study of supervision in the context of a state-funded EBT implementation effort. Verbal interactions from audio recordings of 438 supervision sessions between 28 supervisors and 70 clinicians from 17 public mental health organizations (in 23 offices) were objectively coded for presence and intensity coverage of 29 supervision strategies (16 content and 13 technique items), duration, and temporal focus. Random effects mixed models estimated proportion of variance in content and techniques attributable to the supervisor and clinician levels. RESULTS: Interrater reliability among coders was excellent. EBT cases averaged 12.4 min of supervision per session. Intensity of coverage for EBT content varied, with some discussed frequently at medium or high intensity (exposure) and others infrequently discussed or discussed only at low intensity (behavior management; assigning/reviewing client homework). Other than fidelity assessment, supervision techniques common in treatment trials (e.g., reviewing actual practice, behavioral rehearsal) were used rarely or primarily at low intensity. In general, EBT content clustered more at the clinician level; different techniques clustered at either the clinician or supervisor level. CONCLUSIONS: Workplace-based clinical supervision may be a feasible implementation strategy for supporting EBT implementation, yet it differs from supervision in treatment trials. Time allotted per case is limited, compressing time for EBT coverage. Techniques that involve observation of clinician skills are rarely used. Workplace-based supervision content appears to be tailored to individual clinicians and driven to some degree by the individual supervisor. Our findings point to areas for intervention to enhance the potential of workplace-based supervision for implementation effectiveness. TRIAL REGISTRATION: NCT01800266 , Clinical Trials, Retrospectively Registered (for this descriptive study; registration prior to any intervention [part of phase II RCT, this manuscript is only phase I descriptive results]).

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

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