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Measurement-based care (MBC), including remote MBC, is increasingly being considered or implemented for mental health treatment and outcomes monitoring in routine clinical care. However, little is known about the health equity implications in real-world practice or the impact on patient-provider relationships in lower-resource systems that offer mental health treatment for diverse patients. This hypothesis-generating study examined the drivers of MBC implementation outcomes, the implications for health equity, and the impact of MBC on therapeutic alliance (TA). The study was conducted 1 year after the implementation of remote MBC at 3 outpatient adult clinics in a diverse, safety-net health system. This explanatory sequential mixed methods study used quantitative surveys and qualitative focus groups with mental health care providers. Repeated surveys were first used to understand mental health care provider experiences over a 6-month period, at least 1 year after MBC implementation. Surveys were analyzed to refine focus group prompts. Six mental health providers participated in repeated surveys over 6 months, after which the same 6 providers and 1 additional mental health provider took part in focus groups. Surveys revealed stable acceptability and utility ratings, concerns that MBC was not equally benefiting patients, little endorsement that MBC improved TA, and slightly decreasing feasibility scores. In focus groups, mental health care providers shared concerns about the acceptability, appropriateness, feasibility, and equity of processes for collecting MBC data. These providers had less first-hand experience with sharing and acting upon the data but still voiced concerns about the processes for doing so. TA both impacted and was impacted by MBC in positive and negative ways. The potential drivers of the findings are discussed using qualitative data. More than 1 year after the implementation of remote MBC for mental health, mental health care providers had enduring concerns about its implications for health equity as well as its bidirectional relationship with TA. These findings suggest that further study is needed to identify system-level strategies to mitigate potential negative effects of real-world MBC implementations on health equity, particularly in low-resource settings with diverse populations.

Objective: The objective of this study was to explore the acceptability and feasibility of a therapeutic assessment protocol for the Screening and Support of Youth (SASY). SASY provides brief but comprehensive community-based screening and support for diverse youth in the community. Methods: SASY screening evaluates symptoms, functioning and clinical risk. The Kiddie Computerized Adaptive Test was used to evaluate seven different diagnoses and symptom severity. The Weiss Functional Impairment Rating Scale-Self was used to measure functional impairment. Measures were scored according to nationally developed norms. An algorithm was developed to aggregate symptom and function ratings into an overall score for clinical risk. The results are discussed with participants in a motivational interview designed to promote insight, followed by the opportunity for the participant to engage in an online intervention. Protocol changes necessitated by social distancing during the pandemic led to innovative methods including the use of a QR code for recruitment, integration of both online and offline participation, and expansion from in-person recruitment within the schools to virtual engagement with youth throughout the community. The final sample included disproportionately more Black or African American and Hispanic youth as compared to school and community statistics, suggesting that optimization of online and offline methods in research may facilitate the recruitment of diverse populations. Qualitative interviews indicated that the screening and feedback raised youth awareness of their wellbeing and/or distress, its impact on their functioning, and engagement with options for improved wellbeing. Conclusions: The emergence of innovative methods optimizing the advantages of both online and offline methods, developed as a necessity during the pandemic, proved advantageous to the feasibility and acceptability of community-based recruitment of at-risk, minoritized youth.

Achieving population behavioral health is urgently needed. The mental health system struggles with enormous challenges of providing access to mental health services, improving quality and equitability of care, and ensuring good health outcomes across subpopulations. Little data exists about increasing access within highly constrained resources, staging/sequencing treatment along care pathways, or personalizing treatments. The conceptual model of the learning healthcare system offers a potential paradigm shift for addressing these challenges. In this article we present an overview of how the three constructs of population health, learning health systems, and measurement-based care are inter-related, and we provide an example of how one academic, community-based, safety net health system is approaching integrating these paradigms into its service delivery system. Implementation outcomes will be described in a subsequent publication. We close by discussing how ultimately, to meaningfully improve population behavioral health, a learning healthcare system could expand into a learning health community in order to target critical points of prevention and intervention.

Introduction Psychiatric measurement‐based care (MBC) can be more effective than usual care, but health systems face implementation challenges. Achieving attitudinal alignment before implementing MBC is critical, yet few studies incorporate perspectives from multiple stakeholders this early in planning. This analysis identifies alignment and themes in pre‐implementation feedback from patients, providers, and administrators regarding a planned MBC implementation in a safety net psychiatry clinic. Methods We used interview guides informed by Conceptual Model of Implementation Research to gather qualitative pre‐implementation attitudes about perceived Appropriateness, Acceptability, and Feasibility of an MBC measure (Computerized Adaptive Test—Mental Health; CAT‐MH) from five patients, two providers, and six administrators. We applied rapid qualitative analysis methods to generate actionable feedback for department leadership still planning implementation. [Correction added on 22 January 2025, after first online publication: In the previous sentence, the word ‘general’ was replaced with the word ‘generate’.] We used a multistep process to generate thematic findings with potential relevance for other similar mental health settings. Results There was more attitudinal alignment across stakeholder groups regarding MBC's Acceptability and Feasibility than its Appropriateness. All three groups agreed that it was important to contextualize MBC for patients and providers, anticipate MBC's impact on patient–provider relationships, and consider the system's capacity to respond to patient needs unearthed by CAT‐MH before implementation began. Our thematic analysis suggests: (1) Introducing MBC may complicate patient–provider relationships by adding a new and potentially conflicting input for decision making, that is, MBC data, to the more typical inputs of patient report and provider expertise; [Correction added on 22 January 2025, after first online publication: In the previous sentence, the word ‘complicated’ was replaced with the word ‘complicate’.] (2) MBC poses theoretical risks to health equity for safety net patients because of limitations in access to MBC tools themselves and the resources needed to respond to MBC data; and (3) Tension exists between individual‐ and system‐level applications of MBC. Conclusions Our analysis highlights shifting treatment dynamics, equity considerations, and tension between individual‐ and population‐level needs that our participants anticipated when planning for MBC implementation in a safety net psychiatry clinic.

Introduction Behavioral measurement‐based care (MBC) can improve patient outcomes and has also been advanced as a critical learning health system (LHS) tool for identifying and mitigating potential disparities in mental health treatment. However, little is known about the uptake of remote behavioral MBC in safety net settings, or possible disparities occurring in remote MBC implementation. Methods This study uses electronic health record data to study variation in completion rates at the clinic and patient level of a remote MBC symptom measure tool during the first 6 months of implementation at three adult outpatient psychiatry clinics in a safety net health system. Provider‐reported barriers to MBC adoption were also measured using repeated surveys at one of the three sites. Results Out of 1219 patients who were sent an MBC measure request, uptake of completing at least one measure varied by clinic: General Adult Clinic, 38% (n = 262 of 696); Substance Use Clinic, 28% (n = 73 of 265); and Transitions Clinic, 17% (n = 44 of 258). Compared with White patients, Black and Portuguese or Brazilian patients had lower uptake. Older patients also had lower uptake. Spanish language of care was associated with much lower uptake at the patient level. Significant patient‐level disparities in uptake persisted after adjusting for the clinic, mental health diagnoses, and number of measure requests sent. Providers cited time within visits and bandwidth in their workflow as the greatest consistent barriers to discussing MBC results with patients. Conclusions There are significant disparities in MBC uptake at the patient and clinic level. From an LHS data infrastructure perspective, safety net health systems may need to address the need for possible ways to adapt MBC to better fit their populations and clinical needs, or identify targeted implementation strategies to close data gaps for the identified disparity populations.

The American Psychological Association (APA) has long maintained a close, even symbiotic, relationship with the Department of Defense (DOD) and the Veterans Administration (VA). Herein we highlight these close ties and describe psychologists' participation in interrogations by U.S. military and intelligence entities. We then review the APA's statements about the permissibility of psychologist participation in the interrogation and torture of suspected terrorists. These issues are significant in and of themselves and because the VA and DOD have been described as \"growth careers\" for psychologists of the future (1). Additionally, the Health Care Personnel Delivery System allows the drafting of civilian clinical psychologists into military service even in the absence of a general draft. In light of psychologists' extensive involvement in the interrogation process of suspected terrorists, and the possibility that psychologists without prior military experience may be drafted, we wondered how much psychologists have been taught about their ethical duties should they find themselves in military settings. The results of our pilot study of U.S. psychology graduate students, which assessed their knowledge of military ethics, raise concerns that psychologists receive inadequate formal training in these matters. This may leave psychologists vulnerable to misinformation about proper ethical conduct in their future work.

Studies of HIV care in Pune, a high-HIV-prevalence city in India, have shown that a significant proportion of practitioners were not adhering to national guidelines due to inadequate awareness and understanding. This study examined the effectiveness of a pilot Internet-based continuing medical education course in increasing knowledge of pediatric HIV diagnosis and treatment among providers in Pune. The study also explored perceived factors limiting the effectiveness of the pilot course. The mixed methods evaluation design consisted of quantitative pre- and post-course knowledge assessments, and qualitative focus groups and in-depth interviews conducted on site with healthcare providers with experience treating HIV to explore the barriers to optimal course utilization, the applicability of the course content, and the systemic barriers to the implementation of physician knowledge. There were significant increases (p<0.05) in mean knowledge scores on the global knowledge assessment and for two of five individual course modules. Perceived barriers to optimal course utilization were identified as being related to Internet access. The course content was reported to be generally useful, although certain guidelines and information were described as not congruent with local resource availability. Participants reported that the major barriers to implementing their knowledge were stigma that prevented patients from seeking care and financial resource limitations affecting physician practice. This course resulted in a modest increase in pediatric HIV knowledge among Pune healthcare providers. Identification of perceived factors limiting the effectiveness of the course provides guidance for improving future Internet-based courses.

Background: One of the ways to enhance analyses conducted with large claims databases is by validating the measurement characteristics of code-based algorithms used to identify health outcomes or other key study parameters of interest. These metrics can be used in quantitative bias analyses to assess the robustness of results for an inferential study given potential bias from outcome misclassification. However, extensive time and resource allocation are typically re-quired to create reference-standard labels through manual chart review of free-text notes from linked electronic health records. Methods: We describe an expedited process that introduces efficiency in a validation study us-ing two distinct mechanisms: 1) use of natural language processing (NLP) to reduce time spent by human reviewers to review each chart, and 2) a multi-wave adaptive sampling approach with pre-defined criteria to stop the validation study once performance characteristics are identified with sufficient precision. We illustrate this process in a case study that validates the performance of a claims-based outcome algorithm for intentional self-harm in patients with obesity. Results: We empirically demonstrate that the NLP-assisted annotation process reduced the time spent on review per chart by 40% and use of the pre-defined stopping rule with multi-wave samples would have prevented review of 77% of patient charts with limited compromise to precision in derived measurement characteristics. Conclusion: This approach could facilitate more routine validation of code-based algorithms used to define key study parameters, ultimately enhancing understanding of the reliability of find-ings derived from database studies.