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ABSTRACT BACKGROUND Depression contributes to disability and there are ethnic/racial disparities in access and outcomes of care. Quality improvement (QI) programs for depression in primary care improve outcomes relative to usual care, but health, social and other community-based service sectors also support clients in under-resourced communities. Little is known about effects on client outcomes of strategies to implement depression QI across diverse sectors. OBJECTIVE To compare the effectiveness of Community Engagement and Planning (CEP) and Resources for Services (RS) to implement depression QI on clients’ mental health-related quality of life (HRQL) and services use. DESIGN Matched programs from health, social and other service sectors were randomized to community engagement and planning (promoting inter-agency collaboration) or resources for services (individual program technical assistance plus outreach) to implement depression QI toolkits in Hollywood-Metro and South Los Angeles. PARTICIPANTS From 93 randomized programs, 4,440 clients were screened and of 1,322 depressed by the 8-item Patient Health Questionnaire (PHQ-8) and providing contact information, 1,246 enrolled and 1,018 in 90 programs completed baseline or 6-month follow-up. MEASURES Self-reported mental HRQL and probable depression (primary), physical activity, employment, homelessness risk factors (secondary) and services use. RESULTS CEP was more effective than RS at improving mental HRQL, increasing physical activity and reducing homelessness risk factors, rate of behavioral health hospitalization and medication visits among specialty care users (i.e. psychiatrists, mental health providers) while increasing depression visits among users of primary care/public health for depression and users of faith-based and park programs (each p  < 0.05). Employment, use of antidepressants, and total contacts were not significantly affected (each p  > 0.05). CONCLUSION Community engagement to build a collaborative approach to implementing depression QI across diverse programs was more effective than resources for services for individual programs in improving mental HRQL, physical activity and homelessness risk factors, and shifted utilization away from hospitalizations and specialty medication visits toward primary care and other sectors, offering an expanded health-home model to address multiple disparities for depressed safety-net clients.

Background Despite the availability of psychosocial evidence-based practices (EBPs), treatment and outcomes for persons with mental disorders remain suboptimal. Replicating Effective Programs (REP), an effective implementation strategy, still resulted in less than half of sites using an EBP. The primary aim of this cluster randomized trial is to determine, among sites not initially responding to REP, the effect of adaptive implementation strategies that begin with an External Facilitator (EF) or with an External Facilitator plus an Internal Facilitator (IF) on improved EBP use and patient outcomes in 12 months. Methods/Design This study employs a sequential multiple assignment randomized trial (SMART) design to build an adaptive implementation strategy. The EBP to be implemented is life goals (LG) for patients with mood disorders across 80 community-based outpatient clinics ( N N = 1,600 patients) from different U.S. regions. Sites not initially responding to REP (defined as <50% patients receiving ≥3 EBP sessions) will be randomized to receive additional support from an EF or both EF/IF. Additionally, sites randomized to EF and still not responsive will be randomized to continue with EF alone or to receive EF/IF. The EF provides technical expertise in adapting LG in routine practice, whereas the on-site IF has direct reporting relationships to site leadership to support LG use in routine practice. The primary outcome is mental health-related quality of life; secondary outcomes include receipt of LG sessions, mood symptoms, implementation costs, and organizational change. Discussion This study design will determine whether an off-site EF alone versus the addition of an on-site IF improves EBP uptake and patient outcomes among sites that do not respond initially to REP. It will also examine the value of delaying the provision of EF/IF for sites that continue to not respond despite EF. Trial registration ClinicalTrials.gov identifier: NCT02151331

Frequent users of hospital emergency departments (EDs) are a medically and socially vulnerable population. The Coordinated Access to Care from Hospital EDs (CATCH-ED) study examined the effectiveness of a brief case management intervention in reducing ED use and improving health outcomes among frequent ED users with mental health or addiction challenges in a large urban centre. Adults (≥18 years of age) who had five or more ED visits in the past 12-months, with at least one visit for mental health or addictions problems were randomized to either brief case management (N = 83) or usual care (N = 83) and followed for 12 months. The primary outcome of effectiveness was the frequency of ED visits during 12 months after study enrolment. Secondary outcomes included days in hospital, mental health and addiction symptom severity and health-related quality of life, measured by the SF-12. Compared to usual care, CATCH-ED participants saw a 14% reduction in frequency of ED visits during the 12-month post-randomization period [rate ratio (RR) = 0.86, 95% CI 0.64-1.15)], however, this finding did not reach statistical significance. There were also no statistically significant differences between the groups at 12 months in the number of days spent in hospital (RR = 1.16, 95% CI 0.59-2.29), physical (1.50, 95% CI -2.15-5.15) or mental (-3.97, 95% CI -8.13-0.19) component scores of the SF-12, severity of psychiatric symptoms (-0.41, 95% CI -2.30-1.49), alcohol (0.053 95% -0.017-0.12) or drug (-0.0027, 95% CI -0.0028-0.023) use. Compared to usual care, a brief case management intervention did not result in significantly reduced ED use or improved health outcomes among frequent ED users with mental health or addictions challenges in a large urban centre in Canada. Future studies need to evaluate the availability and accessibility of community-based resources for individuals with frequent ED use.

Background Informed by our prior work indicating that therapists do not feel recognized or rewarded for implementation of evidence-based practices, we tested the feasibility and acceptability of two incentive-based implementation strategies that seek to improve therapist adherence to cognitive-behavioral therapy for youth, an evidence-based practice. Methods This study was conducted over 6 weeks in two community mental health agencies with therapists ( n  = 11) and leaders ( n  = 4). Therapists were randomized to receive either a financial or social incentive if they achieved a predetermined criterion on adherence to cognitive-behavioral therapy. In the first intervention period (block 1; 2 weeks), therapists received the reward they were initially randomized to if they achieved criterion. In the second intervention period (block 2; 2 weeks), therapists received both rewards if they achieved criterion. Therapists recorded 41 sessions across 15 unique clients over the project period. Primary outcomes included feasibility and acceptability. Feasibility was assessed quantitatively. Fifteen semi-structured interviews were conducted with therapists and leaders to assess acceptability. Difference in therapist adherence by condition was examined as an exploratory outcome. Adherence ratings were ascertained using an established and validated observational coding system of cognitive-behavioral therapy. Results Both implementation strategies were feasible and acceptable—however, modifications to study design for the larger trial will be necessary based on participant feedback. With respect to our exploratory analysis, we found a trend suggesting the financial reward may have had a more robust effect on therapist adherence than the social reward. Conclusions Incentive-based implementation strategies can be feasibly administered in community mental health agencies with good acceptability, although iterative pilot work is essential. Larger, fully powered trials are needed to compare the effectiveness of implementation strategies to incentivize and enhance therapists’ adherence to evidence-based practices such as cognitive-behavioral therapy.

Background Increasing numbers of people with mental disorders receive services at primary care in China. The aims of this study are to evaluate impact of a new training course and supervision for community mental health staff to enhance their levels of mental health knowledge and to reduce their stigmatization toward people with mental illness. Methods A total of 77 community mental health staff from eight regions in Guangzhou in China were recruited for the study.4 regions were randomly allocated to the new training model group, and 4 to the old training model group. Levels of mental health knowledge were measured by purpose-made assessment schedule and by the Mental Health Knowledge Schedule (MAKS). Stigma was evaluated by the Mental Illness: Clinicians’ Attitudes Scale (MICA) and the Reported and Intended Behavior Scale (RIBS). Evaluation questionnaires were given at the beginning of course, at the end, and at 6 month and at 12 month follow-up. Results After the training period, the 6-month, and the 12-month, knowledge scores of the intervention group were higher than the control group. At 6-month and 12-month follow-up, means scores of MAKS of the intervention group increased more than the control group (both p  < 0.05) when age, sex, marriage status, title and time were controlled for. At 6-month follow-up, means scores of MICA of the intervention group decreased more than that of the control group ( p  < 0.01). At after-training, at 6-months, and at 12-months, mean scores of RIBS of the intervention group increased more than the control ( p  < 0.01, p  < 0.001, p  < 0.001) when age, sex, marriage status, title and time were controlled for. Conclusions Compared with the traditional training course and supervision, the new course improved community mental health staff knowledge of mental disorders, improving their attitudes toward people with mental disorder, and increasing their willingness to have contact with people with mental disorder.

Measuring quality of care can transform care, but few tools exist to measure quality from the client’s perspective. The aim of this study was to create concordant clinician and client self-report quality-of-care scales in a sample of community mental health clinicians ( n  = 189) and clients ( n  = 469). The client scale had three distinct factors (Person-Centered Care, Negative Staff Interactions, and Inattentive Care), while the clinician scale had two: Person-Centered Care and Discordant Care. Both versions demonstrated adequate internal consistency and validity with measures related to satisfaction and the therapeutic relationship. These measures are promising, brief quality assessment tools.

ABSTRACT BACKGROUND As medical homes are developing under health reform, little is known regarding depression services need and use by diverse safety-net populations in under-resourced communities. For chronic conditions like depression, primary care services may face new opportunities to partner with diverse community service providers, such as those in social service and substance abuse centers, to support a collaborative care model of treating depression. OBJECTIVE To understand the distribution of need and current burden of services for depression in under-resourced, diverse communities in Los Angeles. DESIGN Baseline phase of a participatory trial to improve depression services with data from client screening and follow-up surveys. PARTICIPANTS Of 4,440 clients screened from 93 programs (primary care, mental health, substance abuse, homeless, social and other community services) in 50 agencies, 1,322 were depressed according to an eight-item Patient Health Questionnaire (PHQ-8) and gave contact information; 1,246 enrolled and 981 completed surveys. Ninety-three programs, including 17 primary care/public health, 18 mental health, 20 substance abuse, ten homeless services, and 28 social/other community services, participated. MAIN MEASURES Comparisons by setting in 6-month retrospective recall of depression services use. KEY RESULTS Depression prevalence ranged from 51.9 % in mental health to 17.2 % in social-community programs. Depressed clients used two settings on average to receive depression services; 82 % used any setting. More clients preferred counseling over medication for depression treatment. CONCLUSIONS Need for depression care was high, and a broad range of agencies provide depression care. Although most participants had contact with primary care, most depression services occurred outside of primary care settings, emphasizing the need to coordinate and support the quality of community-based services across diverse community settings.

Background People with severe mental illnesses (SMI) are at increased risk of cardiovascular disease (CVD). Clinical guidelines recommend regular screening for CVD risk factors. We evaluated a nurse led intervention to improve screening rates across the primary-secondary care interface. Methods Six community mental health teams (CMHTs) were randomised to receive either the nurse led intervention plus education pack (n = 3) or education pack only (n = 3). Intervention (6 months): The nurse promoted CVD screening in primary care and then in CMHTs. Patients who remained unscreened were offered screening by the nurse. After the intervention participants with SMI were recruited from each CMHT to collect outcome data. Main outcome: Numbers screened during the six months, confirmed in General Practice notes. Results All six CMHTs approached agreed to randomisation. 121 people with SMI participated in outcome interviews during two waves of recruitment (intervention arm n = 59, control arm n = 62). Participants from both arms of the trial had similar demographic profiles and rates of previous CVD screening in the previous year, with less than 20% having been screened for each risk factor. After the trial, CVD screening had increased in both arms but participants from the intervention arm were significantly more likely to have received screening for blood pressure (96% vs 68%; adjusted Odds Ratio (OR) 13.6; 95% CI: 3.5-38.4), cholesterol (66.7% vs 26.9%, OR 6.1; 3.2-11.5), glucose (66.7% vs 36.5% OR 4.4; 2.7-7.1), BMI (92.5% vs 65.2% OR 6.5; 2.1-19.6), and smoking status (88.2% vs 57.8% OR 5.5; 3.2-9.5) and have a 10 year CVD risk score calculated (38.2% vs 10.9%) OR 5.2 1.8-15.3). Within the intervention arm approximately half the screening was performed in general practice and half by the trial nurse. Conclusions The nurse-led intervention was superior, resulting in an absolute increase of approximately 30% more people with SMI receiving screening for each CVD risk factor. The feasibility of the trial was confirmed in terms of CMHT recruitment and the intervention, but the response rate for outcome collection was disappointing; possibly a result of the cluster design. The trial was not large or long enough to detect changes in risk factors. Trial Registration International Standard Randomised Controlled Trial Registration Number (ISRCTRN) 58625025.

Therapeutic alliance between clinicians and their patients is important in community mental healthcare. It is unclear whether providing effective interventions influences therapeutic alliance. To assess the impact of meeting previously unmet mental health needs on the therapeutic alliance between patients and clinicians. Secondary analysis of data from a longitudinal study assessing 101 patients and paired staff. Patient-rated unmet need was negatively associated with patient-rated and staff-rated therapeutic alliance. Staff-rated unmet need was positively associated with patient-rated therapeutic alliance only. Reducing patient-rated unmet need increased patient-rated but not staff-rated therapeutic alliance, even when controlling for other variables. Reducing staff-rated unmet need increased staff-rated but not patient-rated therapeutic alliance, but the effect became insignificant when controlling for other variables. Patient-rated therapeutic alliance will be maximised by focusing assessment and interventions on patient-rated rather than staff-rated unmet need.

The goal of this paper is to document and evaluate the process of implementing an evidence-based depression intervention in community settings through the use of community-academic partnered approaches. We discuss how and to what extent the goals of community engagement and collaborative planning were achieved in the intervention arm of the Community Partners in Care study that aimed to adapt evidence-based depression care toolkits for diverse agencies in Hollywood and South Los Angeles. We find that partnered research strategies have a potential to effectively engage community members around depression and involve them in intervention planning activities. Our results suggest that successful collaboration among diverse agencies requires that they understand what is expected of them, are comfortable with the role they choose to perform, and have organizational support to contribute to the project. To facilitate the development of collaborative relationships, time and effort should be devoted to explaining how collaboration among diverse agencies may take place.