This study examined the relationship between anger and anxiety in youth in an outpatient anxiety treatment clinic. Participants included 40 primarily female and Caucasian youth, all diagnosed with a primary anxiety disorder. Youth provided ratings of anger, anxiety, and depressive symptoms. We also obtained parent and clinician ratings of anxiety severity. Analyses supported a significant relationship between trait anger and anxiety severity. When rated by youth, trait anger was significantly related to physical symptoms of anxiety and harm avoidance. Youth report of anger symptoms was not related to parent or clinician report of youth anxiety severity. Assessing symptoms of anger in youth with anxiety disorders may be important, as it may be related to higher anxiety symptom severity for some youth. Future research in larger samples is needed to understand the co-occurrence of different components of anger and anxiety disorders and its impact on prognosis and treatment process.
Background: Efforts to increase the implementation of evidence-based interventions come at a time of rising inequality and cuts to public mental health funding. Clinicians in publicly funded mental health clinics face increased demands, work long hours, experience financial stress, and treat clinically severe, under-resourced patients. A detailed understanding of clinicians' economic precarity, financial strain, and job-related stressors, and an understanding of how these factors relate to treatment delivery, is needed. Methods: In July 2020, we surveyed 49 clinicians working in Philadelphia’s public mental health system who participated in a large-scale trauma-focused cognitive behavioral therapy (TF-CBT) training initiative. Respondents reported on professional burnout, economic precarity, financial strain, secondary traumatic stress, and self-reported use of TF-CBT. We examined associations between clinicians’ economic precarity, job-related stressors, and their TF-CBT use with mixed models. We used content coding to organize open-ended responses into themes.Results: Economic precarity, financial strain, burnout, and secondary traumatic stress among respondents was high. Thirty-seven percent of clinicians were independent contractors, and of those, 44% reported desiring a salaried position. Most clinicians (76%) had outstanding education loans, and of those, 38% reported over $100,000 in education debt. In the last year, 29% of clinicians went without personal mental healthcare due to cost. Most clinicians (73%) endorsed at least one symptom of secondary traumatic stress, with 22% scoring above the clinical cutoff. Education debt was negatively associated with TF-CBT use (p<0.001). Secondary traumatic stress, measured continuously and categorically, was associated with burnout (ps<0.05).Discussion: Clinicians in Philadelphia’s public mental health system experience burnout, economic precarity, financial strain, and secondary traumatic stress, which were associated with TF-CBT use. The economic strain and stress of providing care in under-resourced clinical settings may interfere with ongoing efforts to integrate scientific evidence into mental health services. Financial investment in the mental health workforce is essential.
Background Standardized labor induction protocols improve obstetric outcomes. However, these protocols are complex. The Consolidated Framework for Implementation Research describes intervention components as “core” and “adaptable periphery.” We aimed to identify core components by investigating the individual components of an evidence-based protocol most associated with effectiveness. We planned to utilize this information to simplify our protocol prior to multi-site implementation. Methods This is a secondary analysis of an RCT comparing time to delivery among four labor induction methods. All patients enrolled in the trial had their labor managed with a multidisciplinary-developed, evidence-based labor induction protocol. For each patient’s induction, we assessed fidelity to 7 components of the protocol. Primary effectiveness outcomes included cesarean delivery, maternal morbidity, and neonatal morbidity. Bivariate analyses assessed association of each component with each primary effectiveness outcome. Multivariable logistic regression determined independent predictors of each outcome while controlling for demographic and clinical factors known to be related to our outcomes. Results The 491 patients enrolled in the RCT were included in this analysis. While multiple components were associated with each outcome in bivariate analysis, few were found to be independent predictors of effectiveness in multivariable analysis. For cesarean delivery, only one component “for women in active labor, all cervical exams were performed ≤2.5 hours apart” was an independent predictor. For maternal morbidity, only one “if an intracervical Foley catheter was utilized for cervical ripening, it was removed within 12 hours of placement” remained significant. For neonatal morbidity, two components “all cervical exams performed in latent labor were performed ≤4.5 hours apart” and “for women in active labor, all cervical exams were performed ≤2.5 hours apart” remained independent predictors. Of the independent predictors of effectiveness, most reflected the overarching concept of “frequent exams in labor will allow for more frequent intervention when no change is made”.Conclusions This study demonstrates a novel strategy to identify which components of an evidence-based intervention should be “core” and which are “adaptable periphery”; this provides valuable information when designing for dissemination and implementation. With an understanding of the relationship between fidelity to individual protocol components and effectiveness, we can systematically simplify interventions prior to large-scale implementation, a potential strategy to increase implementation success. These data will be used to streamline our protocol to best target cesarean rate and maternal/neonatal morbidity prior to a planned type I hybrid effectiveness-implementation trial.
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