Evidence‐based practice in child and adolescent mental health services – The challenge of implementing national guidelines for treatment of depression and anxiety

Abstract

Background Mental health problems are one of the most pressing public health concerns of our time. Sweden has seen a sharp increase in mental disorders among children and youth during the last decade. The evidence base for treatment of psychiatric conditions has developed strongly. Clinical practice guidelines aim to compile such evidence and support healthcare professionals in evidence‐based clinical decision‐making. In Sweden, the national guidelines for the treatment of depression and anxiety disorders in children and adolescents were launched in 2010. The aim of this study was two folded, (i) to explore to what extent these guidelines were known and adhered to by health professionals in Child and Adolescent Mental Health Services and (ii) to investigate factors influencing implementation of the guidelines informed by the Consolidated Framework for Implementation Research. Methods A qualitative approach was used, and data were collected through interviews with 18 health professionals in Child Mental Health Services in Sweden and a combination of conventional and directed content analyses was used. The Consolidated Framework for Implementation Research guided and structured data collection and analysis. Results The guidelines were largely unknown by health professionals in Child Mental Health Services in all the clinics investigated. Adherence to guideline recommendations was reported as very low. Barriers to implementation were found in relation to the characteristics of the intervention, outer setting, inner setting and characteristics of the individuals involved. Conclusions The government initiative to develop and disseminate the guidelines seems to have made very little impact on health professionals’ clinical practice. The guidelines were poorly aligned with the health professionals’ knowledge and beliefs about effective mental health services for children and youth with depression and anxiety disorders. Suggestions for future efforts to improve the development and implementation of guidelines in Child Mental Health Services settings are given.

Implementation science in adolescent healthcare research: an integrative review

“…Nine different implementation science theories, models or frameworks were applied in the adolescent healthcare research papers included in this review (Table 2 ), with eight of the twelve studies using a single theory, model or framework. The CFIR was the most popular, used alone in four studies [ 15 – 18 ], in combination with the Active Implementation Framework (AIF) and the Implementation Outcomes Taxonomy (IO) in two papers relating to the same study [ 19 , 20 ], and in one study in combination with the PDSA framework [ 21 ]. Two studies used the Knowledge to Action (KTA) model alone [ 22 , 23 ].…”

“…These theories, models and frameworks were applied at various points within studies’ trajectories: in planning and preparation and in delivery of the intervention implementation strategy and processes; in monitoring and evaluation of these implementation strategies; to plan for and enable sustainability of change (Table 2 ). One study only applied a framework (the CFIR) during evaluation, using it as a post-hoc framework for analysis [ 18 ]; another study claimed both the CFIR and PDSA were used for planning purposes but did not explain how [ 21 ]. One study used the CFIR for both planning and evaluation [ 16 ].…”

“…Eleven papers [ 15 – 19 , 21 , 22 , 24 – 27 ] acknowledged the contribution of intervention characteristics as barriers or facilitators to implementation. Two studies cited the intervention source [ 18 , 21 ], noting that where key stakeholders and end-users were involved in development, this facilitated uptake. By contrast, where externally developed (mental health) guidelines showed limited implementation success, this was attributed to developers’ oversimplified understanding of the population and issues [ 18 ].…”

“…Stakeholder perceptions regarding evidence strength and quality were important [ 18 , 21 , 25 , 26 ], whether based on clear theoretical or research grounding [ 25 ] or expert opinion [ 21 ]. Scepticism from health professionals regarding supporting evidence was a barrier to implementation [ 18 ]. Demonstrated evidence of program effectiveness was important for securing continued funding for one intervention [ 26 ].…”

“…The relative advantage of the intervention compared to available alternatives was credited as influential [ 16 , 18 , 20 , 22 , 25 ]. Uptake was enhanced where health professionals believed that implementation could improve the quality of care and services, reduce practice variations, and promote job satisfaction and professionalism [ 16 , 18 , 20 , 22 ].…”