Objectives Empirical study of public behavioral health systems' use of data and their investment in evidence based treatment (EBT) is limited. This study describes trends in state-level EBT investment and research supports from 2001-2012. Methods Multilevel models examined change over time related to state adoption of EBTs, numbers served, and penetration rates for six behavioral health EBTs for adults and children, based on data from the National Association for State Mental Health Program Directors Research Institute (NRI). State supports related to research, evaluation, and information management were also examined. Results Increasing percentages of states reported funding an external research center, promoting the adoption of EBTs through provider contracts, and providing financial incentives for EBTs. Decreasing percentages of states reported promoting EBT adoption through stakeholder mobilization, monitoring fidelity, and specific budget requests. There was greater reported use of adult-focused EBTs (65-80%) compared with youth EBTs (25-50%). Overall penetration rates of EBTs were low (1% - 3%) and EBT adoption by states showed flat or declining trends. SMHAs' investment in data systems and use of research showed little change. Conclusion SMHA investment in EBTs, implementation infrastructure, and use of research has declined. More systematic measurement and examination of these metrics may provide a useful approach for setting priorities, evaluating success of health reform efforts, and making future investments.

The rate of youth with mental health needs is disproportionately high in juvenile justice. Wraparound planning involves families and providers in coordinating juvenile justice, mental health, and other services and supports. This study compares data from two groups of juvenile offenders with mental health problems: 106 youth in a juvenile justice wraparound program called Connections and a historical comparison group of 98 youth in traditional mental health services. Cox regression survival analyses revealed that youth in Connections were significantly less likely to recidivate at all, less likely to recidivate with a felony offense, and served less detention time.

BackgroundThis paper presents the protocol for the National Institute of Mental Health (NIMH)–funded University of Washington’s ALACRITY (Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness) Center (UWAC), which uses human-centered design (HCD) methods to improve the implementation of evidence-based psychosocial interventions (EBPIs). We propose that usability—the degree to which interventions and implementation strategies can be used with ease, efficiency, effectiveness, and satisfaction—is a fundamental, yet poorly understood determinant of implementation.ObjectiveWe present a novel Discover, Design/Build, and Test (DDBT) framework to study usability as an implementation determinant. DDBT will be applied across Center projects to develop scalable and efficient implementation strategies (eg, training tools), modify existing EBPIs to enhance usability, and create usable and nonburdensome decision support tools for quality delivery of EBPIs.MethodsStakeholder participants will be implementation practitioners/intermediaries, mental health clinicians, and patients with mental illness in nonspecialty mental health settings in underresourced communities. Three preplanned projects and 12 pilot studies will employ the DDBT model to (1) identify usability challenges in implementing EBPIs in underresourced settings; (2) iteratively design solutions to overcome these challenges; and (3) compare the solution to the original version of the EPBI or implementation strategy on usability, quality of care, and patient-reported outcomes. The final products from the center will be a streamlined modification and redesign model that will improve the usability of EBPIs and implementation strategies (eg, tools to support EBPI education and decision making); a matrix of modification targets (ie, usability issues) that are both common and unique to EBPIs, strategies, settings, and patient populations; and a compilation of redesign strategies and the relative effectiveness of the redesigned solution compared to the original EBPI or strategy.ResultsThe UWAC received institutional review board approval for the three separate studies in March 2018 and was funded in May 2018.ConclusionsThe outcomes from this center will inform the implementation of EBPIs by identifying cross-cutting features of EBPIs and implementation strategies that influence the use and acceptability of these interventions, actively involving stakeholder clinicians and implementation practitioners in the design of the EBPI modification or implementation strategy solution and identifying the impact of HCD-informed modifications and solutions on intervention effectiveness and quality.Trial RegistrationClinicalTrials.gov NCT03515226 (https://clinicaltrials.gov/ct2/show/NCT03515226), NCT03514394 (https://clinicaltrials.gov/ct2/show/NCT03514394), and NCT03516513 (https://clinicaltrials.gov/ct2/show/NCT03516513).International Registered Report Identifier (IRRID)DERR1-10.2196/14990

BackgroundWorkplace-based clinical supervision as an implementation strategy to support evidence-based treatment (EBT) in public mental health has received limited research attention. A commonly provided infrastructure support, it may offer a relatively cost-neutral implementation strategy for organizations. However, research has not objectively examined workplace-based supervision of EBT and specifically how it might differ from EBT supervision provided in efficacy and effectiveness trials.MethodsData come from a descriptive study of supervision in the context of a state-funded EBT implementation effort. Verbal interactions from audio recordings of 438 supervision sessions between 28 supervisors and 70 clinicians from 17 public mental health organizations (in 23 offices) were objectively coded for presence and intensity coverage of 29 supervision strategies (16 content and 13 technique items), duration, and temporal focus. Random effects mixed models estimated proportion of variance in content and techniques attributable to the supervisor and clinician levels.ResultsInterrater reliability among coders was excellent. EBT cases averaged 12.4 min of supervision per session. Intensity of coverage for EBT content varied, with some discussed frequently at medium or high intensity (exposure) and others infrequently discussed or discussed only at low intensity (behavior management; assigning/reviewing client homework). Other than fidelity assessment, supervision techniques common in treatment trials (e.g., reviewing actual practice, behavioral rehearsal) were used rarely or primarily at low intensity. In general, EBT content clustered more at the clinician level; different techniques clustered at either the clinician or supervisor level.ConclusionsWorkplace-based clinical supervision may be a feasible implementation strategy for supporting EBT implementation, yet it differs from supervision in treatment trials. Time allotted per case is limited, compressing time for EBT coverage. Techniques that involve observation of clinician skills are rarely used. Workplace-based supervision content appears to be tailored to individual clinicians and driven to some degree by the individual supervisor. Our findings point to areas for intervention to enhance the potential of workplace-based supervision for implementation effectiveness.Trial registrationNCT01800266, Clinical Trials, Retrospectively Registered (for this descriptive study; registration prior to any intervention [part of phase II RCT, this manuscript is only phase I descriptive results])Electronic supplementary materialThe online version of this article (10.1186/s13012-017-0708-3) contains supplementary material, which is available to authorized users.

The education sector offers compelling opportunities to address the shortcomings of traditional mental health delivery systems and to prevent and treat youth mental, emotional, and behavioral (MEB) problems. Recognizing that social and emotional wellness is intrinsically related to academic success, schools are moving to adopt multi-tier frameworks based on the public health model that provide a continuum of services to all children, including services to address both academic and MEB problems. In this paper, we review the potential value of multi-tier frameworks in facilitating access to, and increasing the effectiveness of, mental health services in schools and review the empirical support for school-based mental health interventions by tier. We go on to describe a community-academic partnership between the Seattle Public Schools and the University of Washington School Mental Health Assessment, Research, and Training (SMART) Center that exemplifies how multi-tier educational frameworks, research and evidence, and purposeful collaboration can combine to improve development and implementation of a range of school-based strategies focused on MEB needs of students. Finally, we present a set of 10 recommendations that may help guide other research and practice improvement efforts to address MEB problems in youth through effective school mental health programming.

Family treatment drug courts (FTDCs) are an increasingly common approach for serving families involved in child welfare due to parental substance abuse; however, the evidence base for FTDCs remains emergent. This quasi-experimental study replicates previous research on FTDCs by comparing parental substance abuse treatment and child welfare outcomes for 76 FTDC participants to outcomes for 76 parents in the same system who did not participate in the FTDC, using propensity score matching. Data were obtained from the Superior court, FTDC, child welfare, and public substance use treatment service administrative databases. The follow-up window for participants ranged from 1 to 3 years. Results showed FTDC parents had significantly more review and motion hearings, were significantly more likely to enter treatment, entered treatment faster, received more treatment, and were more likely to successfully complete treatment. FTDC children spent significantly less time placed out of home, ended child welfare system involvement sooner, were more likely to be permanently placed and discharged from child welfare, and were more likely to return to parental care. Results demonstrate that FTDCs promote positive treatment and child welfare outcomes without deepening participants' involvement in justice systems.

BackgroundEvidence-based treatments for child mental health problems are not consistently available in public mental health settings. Expanding availability requires workforce training. However, research has demonstrated that training alone is not sufficient for changing provider behavior, suggesting that ongoing intervention-specific supervision or consultation is required. Supervision is notably under-investigated, particularly as provided in public mental health. The degree to which supervision in this setting includes ‘gold standard’ supervision elements from efficacy trials (e.g., session review, model fidelity, outcome monitoring, skill-building) is unknown. The current federally-funded investigation leverages the Washington State Trauma-focused Cognitive Behavioral Therapy Initiative to describe usual supervision practices and test the impact of systematic implementation of gold standard supervision strategies on treatment fidelity and clinical outcomes.Methods/DesignThe study has two phases. We will conduct an initial descriptive study (Phase I) of supervision practices within public mental health in Washington State followed by a randomized controlled trial of gold standard supervision strategies (Phase II), with randomization at the clinician level (i.e., supervisors provide both conditions). Study participants will be 35 supervisors and 130 clinicians in community mental health centers. We will enroll one child per clinician in Phase I (N = 130) and three children per clinician in Phase II (N = 390). We use a multi-level mixed within- and between-subjects longitudinal design. Audio recordings of supervision and therapy sessions will be collected and coded throughout both phases. Child outcome data will be collected at the beginning of treatment and at three and six months into treatment.DiscussionThis study will provide insight into how supervisors can optimally support clinicians delivering evidence-based treatments. Phase I will provide descriptive information, currently unavailable in the literature, about commonly used supervision strategies in community mental health. The Phase II randomized controlled trial of gold standard supervision strategies is, to our knowledge, the first experimental study of gold standard supervision strategies in community mental health and will yield needed information about how to leverage supervision to improve clinician fidelity and client outcomes.Trial registrationClinicalTrials.gov NCT01800266

Many evidence-based treatments (EBTs) for child and adolescent mental health disorders have been developed, but few are available in public mental health settings. This paper describes initial implementation outcomes for a state-funded effort in Washington State to increase EBT availability, via a common elements training and consultation approach focused on 4 major problem areas (anxiety, PTSD, depression, and behavioral problems). Clinicians (N = 180) reported significant improvement in their ability to assess and treat all problem areas at post-consultation. Clinicians from organizations with a supervisor-level “EBT champion” had higher baseline scores on a range of outcomes, but many differences disappeared at post-consultation. Outcomes suggest that a common elements initiative which includes training and consultation may positively impact clinician-level outcomes, and that having “in-house” organizational expertise may provide additional benefits.