CBT for Youth Anxiety: How Does It Fit Within Community Mental Health?

PURPOSE OF REVIEW: We review (1) the empirical literature for cognitive behavioral therapy (CBT) for youth anxiety delivered in community settings, (2) the use of online delivery methods in this process, and (3) identified barriers and facilitators to implementation of CBT for youth anxiety in community mental health clinics (CMHCs). We provide suggestions for future work. RECENT FINDINGS: Meta-analytic reviews of effectiveness studies suggest that outcomes comparable to those of efficacy studies can be achieved in community settings, particularly when in-session exposures occur. Several online programs support delivery of these services, with an evidence base that is promising. The notable barrier to the implementation of services is the cost of implementation and sustainability. Organizational factors such as leadership, culture, and climate are consistently identified as barriers and facilitators depending on their valence and appear to be related to implementation outcomes (e.g., on provider attitudes). The current findings need to be integrated into future studies, with a focus on further identifying facilitators (e.g., champions and online programs) of implementation. There is also the need for efforts to address organizational and individual barriers and to compare ways to reduce costs.

WHO Participates in Effectiveness Research? A Comparison of Effectiveness Trial Clinicians to National Survey Samples.

Findings from research participants in effectiveness treatment trials (i.e., randomized control trials conducted in community rather than research settings) are considered more generalizable than those from participants in efficacy trials. This is especially true for clinician participants, whose characteristics like attitudes towards evidence-based practices (EBPs) may impact treatment implementation and the generalizability of research findings from effectiveness studies. This study compared background characteristics, attitudes toward EBPs, and attitudes towards measurement-based care (MBC) among clinicians participating in a National Institute of Mental-Health (NIMH) funded effectiveness trial, the Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET), to clinician data from nationally representative U.S. survey samples. Results indicated COMET clinicians were significantly younger, less clinically experienced, and were more likely to have a training background in psychology versus other disciplines compared to national survey samples. After controlling for demographics and professional characteristics, COMET clinicians held more positive attitudes towards EBPs and MBC compared to national survey samples. Implications for implementation efforts are discussed.

The Organizational Financial Context of Publicly-Funded Mental Health Clinics: Development and Preliminary Psychometric Evaluation of the Agency Financial Status Scales.

Funding is a major barrier to implementation of evidence-based practices (EBPs) in publicly-funded community mental health clinics (CMHCs). Understanding how best to deploy implementation strategies that address this barrier requires greater clarity on the financial context within agencies. We developed the Agency Financial Status Scales (AFSS) to assess employee perceptions of the level of three hypothesized and theoretical funding related constructs in organizations: (a) perceptions of financial health, (b) financial attitudes toward EBPs, and (c) strategic financial climate. This investigation serves as a preliminary evaluation of this measure. Participants were 239 therapists and 40 supervisors from 25 publicly-funded CMHCs providing outpatient mental health services for young people. Confirmatory factor analysis was used to investigate the latent trait structure of the items. Internal consistency, interrater agreement, concordance between therapists and supervisors, and convergent validity were also examined. A two-factor model measuring perceptions of financial health and strategic financial climate best fit the data. For both of these scales, alpha reliability was acceptable and agreement statistics provided moderate support for aggregation at the organizational level. Analyses supported the convergent validity of the scales. The development and preliminary evaluation of the AFSS is an important first step in understanding the financial context of publicly-funded CMHCs. Though findings from this investigation are promising, additional development and testing are needed to develop a more thorough understanding of the constructs and to improve the validity and reliability of this measure.

Understanding of evidence-based mental health care and the perceived importance of scientific information in a sample of U.S. adults.

OBJECTIVES: This online survey sought to qualitatively ascertain the extent to which a sample of U.S. adults understood the concept of evidence-based mental health care (EBMHC). Additional goals included assessing the perceived importance of scientific information in EBMHC, and examining whether understanding EBMHC and science values varied as a function of participant factors. METHOD: Participants (N = 221) defined EBMHC and rated the importance of scientific information. Open-ended EBMHC definitions were content-coded, and binomial logistic and linear regressions examined predictors of accurately defining EBMHC and of the perceived importance of scientific information. RESULTS: Participants endorsed seven definitions of EBMHC, and only 20% defined it accurately. Having greater knowledge about mental health conditions was associated with understanding EBMHC and with the higher perceived importance of scientific information. Greater help-seeking efficacy also predicted higher perceived importance of scientific information. CONCLUSIONS: Results support customized strategies to promote basic EBMHC education among U.S. adults.

Individualized Progress Measures Are More Acceptable to Clinicians Than Standardized Measures: Results of a National Survey.

Despite research supporting measurement-based care grounded in standardized progress measures, such measures are underutilized by clinicians. Individualized measures of client-specific targets present an alternative, but little is known about their acceptability or use. We compared attitudes toward and use of standardized and individualized progress measures in a national sample of 504 clinicians. Clinicians reported neutral to positive attitudes toward both types of measures, but strongly preferred and were more likely to use individualized measures. Clinician attitudes, theoretical orientation, and work setting predicted assessment preferences and practices. Implications for dissemination and implementation of measurement-based care are discussed.

Adapting CBT for youth anxiety: Flexibility, within fidelity, in different settings.

Anxiety disorders are common in youth, associated with impairments in daily functioning, and often persist into adulthood when untreated. Cognitive behavioral therapy (CBT) for youth anxiety is a well-established intervention and has been modified to fit several treatment settings. Despite decades of results supporting the efficacy of CBT, there is a large gap in access to this treatment and a need to consider how it can best be administered flexibly to increase uptake and personalization. We first discuss the core components of treatment for CBT through the lens of the Coping Cat treatment. Next, we review the empirical findings regarding adjustments made for CBT for youth anxiety delivered (a) in schools, (b) in community settings, (c) through telehealth, (d) through online computer programs, and (e) by caregivers at home. In each setting, we provide specific suggestions for how to implement CBT with flexibility while maintaining fidelity.

A Qualitative Examination of a School-Based Implementation of Computer-Assisted Cognitive-Behavioral Therapy for Child Anxiety.

Mental health treatment in schools has the potential to improve youth treatment access. However, school-specific barriers can make implementing evidence-based interventions difficult. Task-shifting (i.e., training lay staff to implement interventions) and computer-assisted interventions may mitigate these barriers. This paper reports on a qualitative examination of facilitators and barriers of a school-based implementation of a computer-assisted intervention for anxious youth (Camp Cope-A-Lot; CCAL). Participants (N = 45) included school staff in first through fourth grades. Providers attended a training in CCAL and received weekly, hour-long group consultation calls for three months. In the second year, the sustainability of CCAL use was assessed. Qualitative interviews were conducted after the first year (initial implementation) and second year (sustainability). Interviews were analyzed using the Consolidated Framework for Implementation Research domains to classify themes. Although participants reported that CCAL included useful skills, they expressed concerns about recommended session length (45 minutes) and frequency (weekly). Time burden of consultation calls was also a barrier. School staff facilitated implementation by enabling flexible scheduling for youth to be able to participate in the CCAL program. However, the sustainability of the program was limited due to competing school/time demands. Results suggest that even with computer assisted programs, there is a need to tailor interventions and implementation efforts to account for the time restrictions experienced by school-based service providers. Optimal fit between the intervention and specific school is important to maintain the potential benefits of computer-assisted treatments delivered by lay service providers in schools.

Community Study of Outcome Monitoring for Emotional Disorders in Teens (COMET): A comparative effectiveness trial of a transdiagnostic treatment and a measurement feedback system.

Emotional disorders, encompassing a range of anxiety and depressive disorders, are the most prevalent and comorbid psychiatric disorders in adolescence. Unfortunately, evidence-based psychosocial therapies typically focus on single disorders, are rarely adopted by community mental health center clinicians, and effect sizes are modest. This article describes the protocol for a comparative effectiveness study of two novel interventions designed to address these challenges. The first intervention is a transdiagnostic treatment (the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Adolescents, UP-A), a promising new approach that uses a small number of common strategies to treat a broad range of emotional disorders, and their underlying shared emotional vulnerabilities. The second intervention is a standardized measurement feedback system, the Youth Outcomes Questionnaire (YOQ), designed to improve clinical decision making using weekly symptom and relational data. The three study arms are treatment as usual (TAU), TAU plus the YOQ (TAU+), and UP-A (used in combination with the YOQ). The primary aims of the study are to [1] compare the effects of the UP-A and TAU+ to TAU in community mental health clinics, [2] to isolate the effects of measurement and feedback by comparing the UP-A and TAU+ condition, and [3] to examine the mechanisms of action of both interventions. Design considerations and study methods are provided to inform future effectiveness research.