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

Testing Standard and Modular Designs for Psychotherapy Treating Depression, Anxiety, and Conduct Problems in Youth

CONTEXT: Decades of randomized controlled trials have produced separate evidence-based treatments for depression, anxiety, and conduct problems in youth, but these treatments are not often used in clinical practice, and they produce mixed results in trials with the comorbid, complex youths seen in practice. An integrative, modular redesign may help. OBJECTIVE: Standard/separate and modular/integrated arrangements of evidence-based treatments for depression, anxiety, and conduct problems in youth were compared with usual care treatment, with the modular design permitting a multidisorder focus and a flexible application of treatment procedures. DESIGN: Randomized effectiveness trial. SETTING: Ten outpatient clinical service organizations in Massachusetts and Hawaii. PARTICIPANTS: A total of 84 community clinicians were randomly assigned to 1 of 3 conditions for the treatment of 174 clinically referred youths who were 7 to 13 years of age (70% of these youths were boys, and 45% were white). The study was conducted during the period from January 12, 2005 to May 8, 2009. INTERVENTIONS: Standard manual treatment (59 youths [34% of the sample]; cognitive behavioral therapy for depression, cognitive behavioral therapy for anxiety, and behavioral parent training for conduct problems), modular treatment (62 youths [36%]; integrating the procedures of the 3 separate treatments), and usual care (53 youths [30%]). MAIN OUTCOME MEASURES: Outcomes were assessed using weekly youth and parent assessments. These assessments relied on a standardized Brief Problem Checklist and a patient-generated Top Problems Assessment (ie, the severity ratings on the problems that the youths and parents had identified as most important). We also conducted a standardized diagnostic assessment before and after treatment. RESULTS: Mixed effects regression analyses showed that modular treatment produced significantly steeper trajectories of improvement than usual care and standard treatment on multiple Brief Problem Checklist and Top Problems Assessment measures. Youths receiving modular treatment also had significantly fewer diagnoses than youths receiving usual care after treatment. In contrast, outcomes of standard manual treatment did not differ significantly from outcomes of usual care. CONCLUSIONS: The modular approach outperformed usual care and standard evidence-based treatments on multiple clinical outcome measures. The modular approach may be a promising way to build on the strengths of evidence-based treatments, improving their utility and effectiveness with referred youths in clinical practice settings. Trial Registration clinicaltrials.gov Identifier: NCT01178554.Psycholog

Implementing evidence based practices for youth in an HMO: The roles of external ratings and market share

A qualitative study of child clinicians in a non-profit HMO examined implementation of evidence-based practices (EBPs) for anxiety and oppositional defiant disorders using interviews and focus groups with 33 clinicians (97% of participants), and ethnography of emails and meetings. Analysis showed statistical measures of access and service-key elements of rating organizations' "report cards"- were central in creating "pressure" making transition to EBPs difficult. EBPs were secondary to access and service targets. "Research" and "statistics" were perceived as unrealistic, "literature" as lacking authority. Rating organizations should include outcome and fidelity metrics to align market share pressures with children's health

Creating a prepared mental health workforce: comparative illustrations of implementation strategies.

BACKGROUND: Psychotherapy implementation must contend with the task of preparing a mental health workforce to provide the highest quality services to as much of a service population as possible, in high-income as well as low-to-middle income countries. OBJECTIVE: We outline general challenges and solutions and investigate how well various implementation strategies would fit a clinical population. METHODS: Using a data set from a prior cluster randomised trial with a clinically diverse population and 33 intervention practices, we presented multiple illustrations comparing the ability of different implementation strategies to serve youth and families with procedures in which service providers were trained. FINDINGS: A series of survival functions demonstrated that many common implementation strategies are unlikely to create a prepared workforce, given the large and diverse number of practices needed to be mastered by providers. CLINICAL IMPLICATIONS: Benchmark solutions that afforded superior coverage of the service population could be supported through paced learning approaches (ie, training interventions a little at a time) using extensible, modular intervention designs

Improvement in Symptoms Versus Functioning: How Do Our Best Treatments Measure Up? Administration and policy in mental health. doi

Abstract We examined the effects of redefining standards of evidence for treatments targeting childhood mental health problems by expanding outcomes beyond symptom reduction to include functioning. Over 750 treatment protocols from 435 randomized controlled trials were rated based on empirical evidence. Nearly two-thirds (63.9%) demonstrated at least a minimum level of evidence for reducing symptoms; however, only 18.8% of treatments demonstrated evidence for reducing functional impairment. Of those treatments with empirical support for symptom reduction, the majority did not demonstrate empirical support for improvement in functioning because measures of functioning were not included in the studies in which these treatments were tested. However, even when measures of functioning were included, it was much more difficult for treatments to achieve improvement. Among treatments that achieved improvement in functioning, the most notable were Collaborative Problem Solving for disruptive behavior and Cognitive Behavioral Therapy plus Medication for traumatic stress because they demonstrated no support for symptom reduction but good support for improvement in functioning. Results are discussed within the context of evaluating the standards of evidence for treatments and the opportunity to move towards a multidimensional framework whose utility has the potential to exceed the sum of its parts

Driving with roadmaps and dashboards: Using information resources to structure decision models in service organizations

Abstract This paper illustrates the application of design principles for tools that structure clinical decision-making. If the effort to implement evidence-based practices in community services organizations is to be effective, attention must be paid to the decision-making context in which such treatments are delivered. Clinical research trials commonly occur in an environment characterized by structured decision making and expert supports. Technology has great potential to serve mental health organizations by supporting these potentially important contextual features of the research environment, through organization and reporting of clinical data into interpretable information to support decisions and anchor decision-making procedures. This article describes one example of a behavioral health reporting system designed to facilitate clinical and administrative use of evidence-based practices. The design processes underlying this system-mapping of decision points and distillation of performance information at the individual, caseload, and organizational levels-can be implemented to support clinical practice in a wide variety of settings

Revised Child Anxiety and Depression Scale: a Psychometric Examination in Chinese Youth

There remains a need for a disorder-specific inventory of children’s depression and anxiety that can reliably screen anxious and depressive disorder symptomatology in Chinese children. The Revised Child and Anxiety Depression Scale (RCADS) is a self-report questionnaire assessing anxiety and depression in children (Chorpita et al., 2000; Piqueras et al., 2017). This study sought to evaluate its psychometric properties in a Mainland Chinese sample. Students from the 4th to 11th grades (N = 1001) participated in this study. Each of the RCADS subscales, by age and sex, possessed reliability coefficients ranging between.63 and.81. Means and standard deviations for RCADS subscales calculated for the age and sex sub-samples were reported. Participants reported slightly lower levels on five subscales than for Chorpita et al. (2000) normative sample. The scales were significantly and strongly correlated with the Child Behavior Checklist (CBCL) subscales (somatic, withdrawal, anxiety) as well as CBCL internalizing scores. Fit statistics suggested marginal to adequate fit for the six-factor model for the Chinese youth. The present study provides foundational support for the psychometric properties of the RCADS in a large sample of Chinese youth yet indicates that factor structure might be improved through enhanced sampling of culturally relevant symptom expressions

Adapting Current Strategies to Implement Evidence-Based Prevention Programs for Paraprofessional Home Visiting.

This paper describes a strategy for using evidence-based interventions (EBI) that does not require replication and fidelity. Eight parents, identified as positive role models, conducted home visits for 101 low-income Latina and Korean pregnant women. The home visitors, called mentor mothers (MM), were trained in 10 of the practice elements common to 80% of child-focused EBI and how to apply these skills to support mothers in obesity prevention, to increase the duration of breastfeeding, and to reduce depression. MM reported the content and skills utilized on each home visit on mobile phones. Each MM made an average of 153 home visits (SD = 173.3), with 28 of these visits being phone contacts. Body mass index (BMI) at 6 months was significantly associated with the frequency of MM focused on coping with depression (r = .24), but was not related to practice elements used by MM. The duration of breastfeeding was significantly related to the frequency with which MM focused on the topic of breastfeeding (r = .28) and parenting (r = .3), and MM use of attending (r = .24) and relaxation (r = .27). Depression was significantly correlated with the frequency of addressing depression (r = .27), but not to practice elements. MM did use different strategies in the first 150 visits compared to their last 150 visits, reflecting data-informed supervision. Evidence synthesized from EBI was used as a novel training method, with real-time monitoring and data-informed supervision providing evidence of iterative quality improvements in MM behaviors over time, as well as a way for linking implementation processes to outcomes