Lack of reliable and valid measures of therapist competence is a barrier to dissemination and implementation of psychological treatments in global mental health. We developed the ENhancing Assessment of Common Therapeutic factors (ENACT) rating scale for training and supervision across settings varied by culture and access to mental health resources. We employed a four-step process in Nepal: (1) Item generation: We extracted 1,081 items (grouped into 104 domains) from 56 existing tools; role-plays with Nepali therapists generated 11 additional domains. (2) Item relevance: From the 115 domains, Nepali therapists selected 49 domains of therapeutic importance and high comprehensibility. (3) Item utility: We piloted the ENACT scale through rating role-play videotapes, patient session transcripts, and live observations of primary care workers in trainings for psychological treatments and the Mental Health Gap Action Programme (mhGAP). (4) Inter-rater reliability was acceptable for experts (intraclass correlation coefficient, ICC(2,7)=0.88 (95% confidence interval (CI) 0.81—0.93), N=7) and non-specialists (ICC(1,3)=0.67 (95% CI 0.60—0.73), N=34). In sum, the ENACT scale is an 18-item assessment for common factors in psychological treatments, including task-sharing initiatives with non-specialists across cultural settings. Further research is needed to evaluate applications for therapy quality and association with patient outcomes.

Rationale Clinical decision support (CDS) tools leveraging electronic health records (EHRs) have been an approach for addressing challenges in asthma care but remain under-studied through clinical trials. Objectives To assess the effectiveness and efficiency of Asthma-Guidance and Prediction System (A-GPS), an Artificial Intelligence (AI)-assisted CDS tool, in optimizing asthma management through a randomized clinical trial (RCT). Methods This was a single-center pragmatic RCT with a stratified randomization design conducted for one year in the primary care pediatric practice of the Mayo Clinic, MN. Children (<18 years) diagnosed with asthma receiving care at the study site were enrolled along with their 42 primary care providers. Study subjects were stratified into three strata (based on asthma severity, asthma care status, and asthma diagnosis) and were blinded to the assigned groups. Measurements Intervention was a quarterly A-GPS report to clinicians including relevant clinical information for asthma management from EHRs and machine learning-based prediction for risk of asthma exacerbation (AE). Primary endpoint was the occurrence of AE within 1 year and secondary outcomes included time required for clinicians to review EHRs for asthma management. Main results Out of 555 participants invited to the study, 184 consented for the study and were randomized (90 in intervention and 94 in control group). Median age of 184 participants was 8.5 years. While the proportion of children with AE in both groups decreased from the baseline (P = 0.042), there was no difference in AE frequency between the two groups (12% for the intervention group vs. 15% for the control group, Odds Ratio: 0.82; 95%CI 0.374–1.96; P = 0.626) during the study period. For the secondary end points, A-GPS intervention, however, significantly reduced time for reviewing EHRs for asthma management of each participant (median: 3.5 min, IQR: 2–5), compared to usual care without A-GPS (median: 11.3 min, IQR: 6.3–15); p<0.001). Mean health care costs with 95%CI of children during the trial (compared to before the trial) in the intervention group were lower than those in the control group (-$1,036 [-$2177, $44] for the intervention group vs. +$80 [-$841, $1000] for the control group), though there was no significant difference (p = 0.12). Among those who experienced the first AE during the study period (n = 25), those in the intervention group had timelier follow up by the clinical care team compared to those in the control group but no significant difference was found (HR = 1.93; 95% CI: 0.82–1.45, P = 0.10). There was no difference in the proportion of duration when patients had well-controlled asthma during the study period between the intervention and the control groups. Conclusions While A-GPS-based intervention showed similar reduction in AE events to usual care, it might reduce clinicians’ burden for EHRs review resulting in efficient asthma management. A larger RCT is needed for further studying the findings. Trial registration ClinicalTrials.gov Identifier: NCT02865967.

Background: There is evidence for benefits of psychological treatments in low-resource countries, yet few government health systems include psychological services. Aim: Evaluating the clinical value of adding psychological treatments, delivered by community-based counselors, to primary care-based mental health services for depression and alcohol use disorder (AUD), as recommended by the mental health Gap Action Progamme (mhGAP). Method: Two pragmatic randomized controlled trials, separately for depression and AUD. Participants were randomly allocated (1:1) to mental health care delivered by mhGAP-trained primary care workers (psychoeducation and psychotropic medicines when indicated), or the same services plus individual psychological treatments (Healthy Activity Program for depression and Counselling for Alcohol Problems). Primary outcomes were symptom severity 12 months post-enrolment, using the Patient Health Questionnaire (PHQ-9) for depression, the Alcohol Use Disorder Identification Test for AUD, and functional impairment using the World Health Organisation Disability Assessment Schedule (WHODAS). Results: Participants with depression in the intervention arm (n=60) had greater reduction in PHQ-9 and WHODAS scores compared to participants in the control arm (n=60) (PHQ-9: M=−5.90, 95%CI −7.55 to −4.25, β=−3.68, 95%CI −5.68 to −1.67, p<0.001; Cohen’s d = .66; WHODAS: M=−12.21, 95%CI −19.58 to −4.84, β=−10.74, 95%CI −19.96 to −1.53, p=0.022; Cohen’s d = .42). For the AUD trial, no significant effect was found when comparing control (n=80) and intervention participants (n=82). Conclusion: Adding a psychological treatment delivered by community-based counsellors increases treatment effects for depression compared to only mhGAP-based services by primary health workers 12 months post-treatment. Trial registration: ISRCTN72875710 (protocol available: https://www.isrctn.com/)

Background Because of the high burden of untreated mental illness in humanitarian settings and low- and middle-income countries, scaling-up effective psychological interventions require a cultural adaptation process that is feasible and acceptable. Our adaptation process incorporates changes into both content and implementation strategies, with a focus on local understandings of distress and treatment mechanisms of action. Methods Building upon the ecological validity model, we developed a 10-step process, the mental health Cultural Adaptation and Contextualization for Implementation (mhCACI) procedure, and piloted this approach in Nepal for Group Problem Management Plus (PM+), a task-sharing intervention, proven effective for adults with psychological distress in low-resource settings. Detailed documentation tools were used to ensure rigor and transparency during the adaptation process. Findings The mhCACI is a 10-step process: (1) identify mechanisms of action, (2) conduct a literature desk review for the culture and context, (3) conduct a training-of-trainers, (4) translate intervention materials, (5) conduct an expert read-through of the materials, (6) qualitative assessment of intervention population and site, (7) conduct practice rounds, (8) conduct an adaptation workshop with experts and implementers, (9) pilot test the training, supervision, and implementation, and (10) review through process evaluation. For Group PM+, key adaptations were harmonizing the mechanisms of action with cultural models of ‘tension’; modification of recruitment procedures to assure fit; and development of a skills checklist. Conclusion A 10-step mhCACI process could feasibly be implemented in a humanitarian setting to rapidly prepare a psychological intervention for widespread implementation.