"Can we walk?" Environmental supports for physical activity in India.

India is currently facing a non-communicable disease epidemic. Physical activity (PA) is a preventative factor for non-communicable diseases. Understanding the role of the built environment (BE) to facilitate or constrain PA is essential for public health interventions to increase population PA. The objective of this study was to understand BEs associations with PA occurring in two major life domains or life areas-travel and leisure-in urban India. Between December 2014 and April 2015, in-person surveys were conducted with participants (N=370; female=47.2%) in Chennai, India. Perceived BE characteristics regarding residential density, land use mix-diversity, land use mix-access, street connectivity, infrastructure for walking and bicycling, aesthetics, traffic safety, and safety from crime were measured using the adapted Neighborhood Environment Walkability Scale-India (NEWS-India). Self-reported PA was measured the International Physical Activity Questionnaire. High residential density was associated with greater odds of travel PA (aOR=1.9, 95% CI=1.2, 3.2). Land use mix-diversity was positively related to travel PA (aOR=2.1, 95%CI=1.2, 3.6), but not associated with leisure or total PA. The aggregate NEWS-India score predicted a two-fold increase in odds of travel PA (aOR=1.9, 95% CI=1.1, 3.1) and a 40% decrease in odds of leisure PA (aOR=0.6, 95% CI=0.4, 1.0). However, the association of the aggregated score with leisure PA was not significant. Results suggest that relationships between BE and PA in low-and-middle income countries may be context-specific, and may differ markedly from higher income countries. Findings have public health implications for India suggesting that caution should be taken when translating evidence across countries.

Medicaid Disenrollment Patterns Among Children Coming into Contact with Child Welfare Agencies.

Objectives To examine retention of Medicaid coverage over time for children in the child welfare system. Methods We linked a national survey of children with histories of abuse and neglect to their Medicaid claims files from 36 states, and followed these children over a 4 year period. We estimated a Cox proportional hazards model on time to first disenrollment from Medicaid. Results Half of our sample (50 %) retained Medicaid coverage across 4 years of follow up. Most disenrollments occurred in year 4. Being 3-5 years of age and rural residence were associated with increased hazard of insurance loss. Fee-for-service Medicaid and other non-managed insurance arrangements were associated with a lower hazard of insurance loss. Conclusions for Practice A considerable number of children entering child environments seem to retain Medicaid coverage over multiple years. Finding ways to promote entry of child welfare-involved children into health insurance coverage will be critical to assure services for this highly vulnerable population.

Morbid Obesity and Use of Second Generation Antipsychotics among Adolescents in Foster Care: Evidence from Medicaid.

BACKGROUND: Many adolescents enter foster care with high body mass index (BMI), and patterns of treatment further exacerbate the risk of morbid obesity. A principal risk factor for such exacerbation is the use of second generation antipsychotics (SGAs). We examine the association between receiving a morbid obesity diagnosis and SGA prescriptions among adolescents in foster care. METHODS: We analyzed claims from 36 states' Medicaid Analytic Extract (MAX) files for 2000 through 2003. Obesity diagnoses were ascertained through a primary or secondary diagnosis claim of morbid obesity. Covariates included gender, race/ethnicity. age, insurance status, state obesity rate, and state fixed effects. We calculated relative risks of a diagnosis based upon four SGAs (clozapine, olanzapine, quetiapine, and risperidone) associated with obesity and a polypharmacy indicator. RESULTS: Of the 1,261,806 foster care adolescent-years in the MAX files, 6,517 were diagnosed with morbid obesity, an annual prevalence of 0.5%. The risk of a morbid obesity diagnosis is much higher for female and non-white adolescents. The risk increases with age. Quetiapine and clozapine increased the risk of a morbid obesity diagnosis more than 2.5 times, and two or more psychotropic drugs (polypharmacy) increased the risk fivefold. CONCLUSIONS: Adolescents in foster care are much more likely to be on SGA medications, and therefore may be more susceptible to weight gain and obesity. Given that SGA prescribing for younger populations has only expanded since these data were released, our study may actually understate the magnitude of the problem. Care is needed when prescribing SGAs for foster care adolescents.

Psychotropic drug use among preschool children in the Medicaid program from 36 states.

OBJECTIVES: We determined the prevalence of and indications for psychotropic medication among preschool children in Medicaid. METHODS: We obtained 2000 to 2003 Medicaid Analytic Extract data from 36 states. We followed children in 2 cohorts, born in 1999 and 2000, up to age 4 years. We used logistic regression to model odds of receiving medications for (1) attention-deficit disorder/attention-deficit hyperactivity disorder, (2) depression or anxiety, and (3) psychotic illness or bipolar. RESULTS: Overall, 1.19% of children received at least 1 psychotropic drug. Medications for attention-deficit disorder/attention-deficit hyperactivity disorder treatment were most common (0.61% of all children), followed by depression or anxiety (0.59%) and psychotic illness or bipolar (0.24%). Among children, boys, those of other or unknown race compared with White, and those with other insurance compared with fee for service-only had higher odds of receiving a prescription (odds ratio [OR]=1.80 [95% confidence interval (CI)=1.74, 1.86], 1.75 [corrected] [1.66, 1.85], and 1.14 [1.01, 1.28], respectively), whereas Black and Hispanic children had lower odds (OR=0.51 [95% CI=0.48, 0.53] and 0.37 [0.34, 0.39], respectively). CONCLUSIONS: Preschoolers are receiving psychotropic medications despite limited evidence supporting safety or efficacy. Future research should focus on implementing medication use practice parameters in infant and toddler clinics, and expanding psychosocial interventions for young children with behavioral problems.

The Hutong effect: informal social control and community psychology in Beijing.

BACKGROUND: Nearly 2.4 million Beijing residents experience intimate partner violence (IPV) annually. Of these 2.4 million, over 800 000 are injured by IPV; more than 300 000 are injured badly enough to require medical attention. Informal social control exerted by neighbours in communities with high levels of family-community integration (like those made up of residents of traditional courtyard house-and-alley Beijing neighbourhoods called 'Hutongs') may protect against IPV injury compared with apartment dwellers. METHODS: We tested the protective effects of informal social control and Hutong residence in a randomly selected, three-stage cluster sample of Beijing families reporting IPV. Informal social control of IPV (ISC_IPV) was measured using two 7-question Likert scales developed by the first author. Interviewers were given detailed instructions on how to classify neighbourhoods as Hutong-style or not. We used a Sobel test to examine whether the Hutong effect was mediated by informal social control. The initial sample was of 506 families. Analyses were carried out on 113 families who reported any IPV in the last year. RESULTS: Random effects regression models showed that both acts of informal social control and Hutong residence were associated with less IPV injury. However, the protective finding for Hutong residence was not explained by informal social control, collective efficacy, characteristics of the IPV or demographic characteristics of respondents and households. CONCLUSIONS: The unique protective association with Hutong residence suggests that the benefits of community life remain insufficiently theorised and understood.

Why Patient-Centered Built Environment Standards Matter More Than Numbers of Beds in Inpatient Psychiatry.

This article canvasses extant literature about values, evidence, and standards for inpatient psychiatry units' design. It then analyzes apparent trade-offs between quality of care and access to care using empirical and ethical lenses. From this analysis, the authors conclude that standards for the built environment of inpatient psychiatric care should align with patient-centeredness, even if a downstream consequence of implementing new patient-centered designs is a reduction in beds, although this secondary outcome is unlikely.

Cost-effectiveness of train-the-trainer versus expert consultation training models for implementing interpersonal psychotherapy in college mental health settings: evidence from a national cluster randomized trial.

BACKGROUND: This study is a cost-effectiveness study of two implementation strategies designed to train therapists in college and university counseling centers to deliver interpersonal psychotherapy. Costs of implementing a train-the-trainer (TTT) strategy versus an expert consultation strategy were estimated, and their relative effects upon therapist outcomes were calculated and compared. METHODS: Twenty four counseling centers were recruited across the United States. These centers were randomized to either a TTT (experimental) condition, in which an in-house therapist trained other center therapists, or an expert consultation condition, in which center therapists participated in a workshop and received 12 months of ongoing supervision. The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, assessed via audio recordings of therapy sessions, and analyzed using linear mixed models. Costs of each condition were quantified using time-driven activity-based costing methods, and involved a costing survey administered to center directors, follow up interviews and validation checks, and comparison of time tracking logs of trainers in the expert condition. Mean costs to produce one therapist were obtained for each condition. The costs to produce equivalent improvements in therapist-level outcomes were then compared between the two conditions. RESULTS: Mean cost incurred by counseling centers to train one therapist using the TTT strategy was $3,407 (median = $3,077); mean cost to produce one trained therapist in the control condition was $2,055 (median = $1,932). Therapists in the TTT condition, on average, demonstrated a 0.043 higher adherence score compared to therapists in the control condition; however, this difference was not statistically significant. For the competence outcome, effect size for therapists in the TTT condition was in the large range (1.16; 95% CI: 0.85-1.46; p < .001), and therapists in this condition, on average, demonstrated a 0.073 higher competence score compared to those in the expert consultation condition (95% CI, 0.008-0.14; p = .03). Counseling centers that used the TTT model incurred $353 less in training costs to produce equivalent improvements in therapist competence. CONCLUSIONS: Despite its higher short run costs, the TTT implementation strategy produces greater increases in therapist competence when compared to expert consultation. Expanding resources to support this platform for service delivery can be an effective way to enhance the mental health care of young people seeking care in college and university counseling centers. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02079142.

Revisiting the policy ecology framework for implementation of evidence-based practices in mental health settings.

BACKGROUND: Over the past three decades, policy actors and actions have been highly influential in supporting the implementation of evidence-based practices (EBPs) in mental health settings. An early examination of these actions resulted in the Policy Ecology Framework (PEF), which was originally developed as a tactical primer for state and local mental health regulators in the field of child mental health. However, the policy landscape for implementation has evolved significantly since the original PEF was published. An interrogation of the strategies originally proposed in the PEF is necessary to provide an updated menu of strategies to improve our understanding of the mechanisms of policy action and promote system improvement. OBJECTIVES: This paper builds upon the original PEF to address changes in the policy landscape for the implementation of mental health EBPs between 2009 and 2022. We review the current state of policy strategies that support the implementation of EBPs in mental health care and outline key areas for policy-oriented implementation research. Our review identifies policy strategies at federal, state, agency, and organizational levels, and highlights developments in the social context in which EBPs are implemented. Furthermore, our review is organized around some key changes that occurred across each PEF domain that span organizational, agency, political, and social contexts along with subdomains within each area. DISCUSSION: We present an updated menu of policy strategies to support the implementation of EBPs in mental health settings. This updated menu of strategies considers the broad range of conceptual developments and changes in the policy landscape. These developments have occurred across the organizational, agency, political, and social contexts and are important for policymakers to consider in the context of supporting the implementation of EBPs. The updated PEF expands and enhances the specification of policy levers currently available, and identifies policy targets that are underdeveloped (e.g., de-implementation and sustainment) but are becoming visible opportunities for policy to support system improvement. The updated PEF clarifies current policy efforts within the field of implementation science in health to conceptualize and better operationalize the role of policy in the implementation of EBPs.

Methodologies to Advance a "Science of How": Identifying and Engaging Intervention Targets and Outcomes.

OBJECTIVE: Although implementation science has taken hold in many areas of psychiatric services research, a need remains for developing effective, low-cost interventions for specific subpopulations with mental health conditions. The experimental therapeutics approach has gained momentum as a framework for developing effective interventions. However, few studies have taken steps to rigorously apply experimental therapeutics. This article provides a blueprint for applying this approach. METHODS: A focused literature review was conducted to document the frequency of the application of experimental therapeutics among articles published between 2011 and 2021 in some of the American Psychiatric Association's journals. Independently of the review, the authors delineated a four-component approach for applying experimental therapeutics in research and present practical, innovative strategies to advance psychiatric services research. RESULTS: The four-component approach includes outlining prerequisites, identifying target mechanisms, proposing intervention strategies to address target mechanisms, and using advanced analytic methods. The strategies described for each component are not exhaustive; rather, they suggest promising avenues for research that can lead to more effective interventions and deeper understanding of how, and for whom, an intervention works. CONCLUSIONS: The application of experimental therapeutics in psychiatric services research can lead to increased development, refinement, and implementation of effective interventions for specific populations or conditions.

Outcomes for implementation research: conceptual distinctions, measurement challenges, and research agenda.

An unresolved issue in the field of implementation research is how to conceptualize and evaluate successful implementation. This paper advances the concept of "implementation outcomes" distinct from service system and clinical treatment outcomes. This paper proposes a heuristic, working "taxonomy" of eight conceptually distinct implementation outcomes-acceptability, adoption, appropriateness, feasibility, fidelity, implementation cost, penetration, and sustainability-along with their nominal definitions. We propose a two-pronged agenda for research on implementation outcomes. Conceptualizing and measuring implementation outcomes will advance understanding of implementation processes, enhance efficiency in implementation research, and pave the way for studies of the comparative effectiveness of implementation strategies.

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.

Maintenance of Training Effects of Two Models for Implementing Evidence-Based Psychological Treatment.

OBJECTIVE: The authors compared maintenance of training outcomes for two approaches to training college therapists in interpersonal psychotherapy (IPT): train the trainer versus expert training. METHODS: A cluster-randomized trial was conducted in 24 college counseling centers. Therapists were recruited from enrolled centers, and the therapists enrolled students with depression and eating disorder symptoms. The therapists (N=184) provided data during baseline, posttraining (during the 12 months of expert consultation offered to the expert training group), and maintenance (approximately 7 months after the expert consultation ended). Outcomes were therapist fidelity (i.e., adherence and competence) and IPT knowledge. RESULTS: Both groups showed within-group improvement from baseline to the maintenance period for adherence, competence, and IPT knowledge; however, the train-the-trainer group had greater improvement over time in adherence and competence. CONCLUSIONS: Given that the effects of the train-the-trainer approach were better maintained, and this model's potential to train more therapists over time, the train-the-trainer approach may help increase dissemination of evidence-based treatments such as IPT.

A preliminary analysis of the receipt of mental health services consistent with national standards among children in the child welfare system.

OBJECTIVES: We sought to examine the extent to which children in the child welfare system receive mental health care consistent with national standards. METHODS: We used data from 4 waves (3 years of follow-up) of the National Survey of Child and Adolescent Well-Being, the nation's first longitudinal study of children in the child welfare system, and the Area Resource File to examine rates of screening, assessment, and referral to mental health services among 3802 youths presenting to child welfare agencies. Weighted population-averaged logistic regression models were used to identify variables associated with standards-consistent care. RESULTS: Only half of all children in the sample received care consistent with any 1 national standard, and less than one tenth received care consistent with all of them. Older children, those exhibiting externalizing behaviors, and those placed in foster care had, on average, higher odds of receiving care consistent with national standards. CONCLUSIONS: Adverse consequences of childhood disadvantage cannot be reduced unless greater collaboration occurs between child welfare and mental health agencies. Current changes to Medicaid regulations that weaken entitlements to screening and assessment may also worsen mental health disparities among these vulnerable children.

Using risk adjustment approaches in child welfare performance measurement: Applications and insights from health and mental health settings.

Federal policymaking in the last decade has dramatically expanded performance measurement within child welfare systems, and states are currently being fiscally penalized for poor performance on defined outcomes. However, in contrast to performance measurement in health settings, current policy holds child welfare systems solely responsible for meeting outcomes, largely without taking into account the effects of factors at the level of the child, and his or her social ecology, that might undermine the performance of child welfare agencies. Appropriate measurement of performance is predicated upon the ability to disentangle individual, as opposed to organizational, determinants of outcomes, which is the goal of risk adjustment methodologies. This review briefly conceptualizes and examines risk adjustment approaches in health and child welfare, suggests approaches to expanding its use to appropriately measure the performance of child welfare agencies, and highlights research gaps that diminish the appropriate use of risk adjustment approaches - and which consequently suggest the need for caution - in policymaking around performance measurement of child welfare agencies.

Training Models for Implementing Evidence-Based Psychological Treatment: A Cluster-Randomized Trial in College Counseling Centers.

Importance: Progress has been made in establishing evidence-based treatments for psychiatric disorders, but these are not often delivered in routine settings. A scalable solution for training clinicians in evidence-based treatments is needed. Objective: To compare 2 methods of training college (university) counseling center therapists to treat psychiatric disorders using interpersonal psychotherapy. The hypothesis was that the train-the-trainer condition would demonstrate superior implementation outcomes vs the expert condition. Moderating factors were also explored. Design, Setting, and Participants: This cluster-randomized trial was conducted from October 2012 to December 2017 in 24 college counseling centers across the United States. Therapist participants were recruited from enrolled centers, and student patients with symptoms of depression and eating disorders were recruited by therapists. Data were analyzed from 184 enrolled therapists. Interventions: Counseling centers were randomized to the expert condition, which involved a workshop and 12 months of follow-up consultation, or the train-the-trainer condition, in which a staff member from the counseling center was coached to train other staff members. Main Outcomes and Measures: The main outcome was therapist fidelity (adherence and competence) to interpersonal psychotherapy, as assessed via audio recordings of therapy sessions. Therapist knowledge of interpersonal psychotherapy was a secondary outcome. Result: A total of 184 therapists (mean [SD] age, 41.9 [10.6] years; 140 female [76.1%]; 142 white [77.2%]) were included. Both the train-the-trainer-condition and expert-condition groups showed significant within-group improvement for adherence to interpersonal psychotherapy (change: 0.233 [95% CI, 0.192-0.274] and 0.190 [0.145-0.235], respectively; both P < .001), with large effect sizes (1.64 [95% CI, 1.35-1.93] and 1.34 [95% CI, 1.02-1.66], respectively) and no significant difference between conditions. Both groups also showed significant within-group improvement in interpersonal therapy competence (change: 0.179 [95% CI, 0.132-0.226] and 0.106 [0.059-0.153], respectively; both P < .001), with a large effect size for the train-the-trainer condition (1.16 [95% CI, 0.85-1.46]; P < .001) and a significant difference between groups favoring the train-the-trainer condition (effect size, 0.47 [95% CI, 0.05-0.89]; P = .03). Knowledge of interpersonal psychotherapy improved significantly within both groups (effect sizes: train-the-trainer, 0.64 [95% CI, 0.28-0.99]; P = .005; expert, 0.69 [95% CI, 0.38-1.01]; P < .001), with no significant difference between groups. The significant moderating factors were job satisfaction for adherence (b, 0.120 [95% CI, 0.001-0.24]; P = .048) and competence (b, 0.133 [95% CI, 0.001-0.27]; P = .048), and frequency of clinical supervision for competence (b, 0.05 [95% CI, 0.004-0.09]; P = .03). Conclusions and Relevance: Results demonstrate that the train-the-trainer model produced training outcomes comparable with the expert model for adherence and was superior on competence. Given its potential capability to train more therapists over time, it has the potential to facilitate widespread dissemination of evidence-based treatments. Trial Registration: ClinicalTrials.gov Identifier: NCT02079142.

Toward an Experimental Therapeutics Approach in Human Services Research.

Over the past decade, the experimental therapeutics approach has gained currency as an organizing framework for research in mental health. However, examples of this approach outside of person-directed therapeutic and preventive interventions have been relatively uncommon. This article describes an experimental therapeutics approach to mental health and human services research that considers the role of social and ecological determinants in a person's recovery from mental disorder. To illustrate this approach, this article decomposes an employment intervention to show three of its components and identifies the targets for two components: social relationships and health insurance. These targets can be engaged by provider-, community-, or policy-level interventions. Such applications of an experimental therapeutics approach to research on mental health services can enhance the rigor of studies and thereby contribute to the well-being of persons living with mental disorders in the United States.

Longitudinal patterns of health insurance coverage among a national sample of children in the child welfare system.

OBJECTIVES: We sought to describe health insurance coverage over time among a national sample of children who came into contact with child welfare or child protective services agencies. METHODS: We used data from 4 waves of the National Survey of Child and Adolescent Well-Being to examine insurance coverage among 2501 youths. Longitudinal insurance trajectories were identified using latent class analyses, a technique used to classify individuals into groupings of observed variables, and survey-weighted logistic regression was used to identify variables associated with class membership. RESULTS: We identified 2 latent insurance classes--1 contained children who gained health insurance, and the other contained children who stably maintained coverage over time. History of sexual abuse, and race/ethnicity other than White, Black, and Hispanic, were associated with membership in the "gainer" class. Foster care placement and poorer health status were associated with membership in the "maintainer" class. Caregiver characteristics were not associated with class membership. CONCLUSIONS: The majority of children in child welfare had stable health insurance coverage over time. Given this vulnerable population's dependence upon Medicaid, protection of existing entitlements to Medicaid is essential to preserve their stable insurance coverage.

Population Health in Pediatric Speech and Language Disorders: Available Data Sources and a Research Agenda for the Field.

Purpose: The aim of the study was to provide an overview of population science as applied to speech and language disorders, illustrate data sources, and advance a research agenda on the epidemiology of these conditions. Method: Computer-aided database searches were performed to identify key national surveys and other sources of data necessary to establish the incidence, prevalence, and course and outcome of speech and language disorders. This article also summarizes a research agenda that could enhance our understanding of the epidemiology of these disorders. Results: Although the data yielded estimates of prevalence and incidence for speech and language disorders, existing sources of data are inadequate to establish reliable rates of incidence, prevalence, and outcomes for speech and language disorders at the population level. Conclusions: Greater support for inclusion of speech and language disorder-relevant questions is necessary in national health surveys to build the population science in the field.

Psychotropic Polypharmacy Among Youths With Serious Emotional and Behavioral Disorders Receiving Coordinated Care Services.

OBJECTIVE: The study examined differences in psychotropic polypharmacy among youths with serious emotional and behavioral disorders who received coordinated care services (CCS) that used a wraparound model and a matched sample of youths who received traditional services. METHODS: A quasi-experimental design compared psychotropic polypharmacy one year before and one year after discharge from CCS. The cohort was youths with serious emotional and behavioral disorders who were enrolled in CCS from December 2009 through May 2014. The comparison group was youths with serious emotional and behavioral disorders who received outpatient mental health services during the same time. Administrative data from Medicaid, child welfare, and juvenile justice services were used. A difference-in-difference analysis with propensity score matching evaluated the CCS intervention by time effect on psychotropic polypharmacy. RESULTS: In both groups, most youths were male, black, and 10-18 years old, with attention-deficit hyperactivity disorder (54%-55%), mood disorder (39%-42%), depression (26%-27%), and bipolar disorder (25%-26%). About half of each group was taking an antipsychotic. The percentage reduction in polypharmacy from one year before CCS enrollment to one year after discharge was 28% for the CCS group and 29% for the non-CCS group, a nonsignificant difference. CCS youths excluded from the analysis had more complex mental health needs and a greater change in polypharmacy than the CCS youths who were included in the analytic sample. CONCLUSIONS: Mental health care coordination had limited impact in reducing psychotropic polypharmacy for youths with less complex mental health needs. Further research is needed to evaluate the effect on psychotropic polypharmacy among youths with the greatest mental health needs.