Abstract
BackgroundDepressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT) can improve outcomes, but numerous barriers limit access among affected youth. Many youth try to access mental health services in schools, but school professionals (SPs: counselors, psychologists, social workers) are rarely trained adequately in CBT methods. Further, SPs face organizational barriers to providing CBT, such as lack of administrative support. Three promising implementation strategies to address barriers to school-based CBT delivery include (1) Replicating Effective Programs (REP), which deploys customized CBT packaging, didactic training in CBT, and technical assistance; (2) coaching, which extends training via live supervision to improve SP competence in CBT delivery; and (3) facilitation, which employs an organizational expert who mentors SPs in strategic thinking to promote self-efficacy in garnering administrative support. REP is a relatively low-intensity/low-cost strategy, whereas coaching and facilitation require additional resources. However, not all schools will require all three strategies. The primary aim of this study is to compare the effectiveness of a school-level adaptive implementation intervention involving REP, coaching, and facilitation versus REP alone on the frequency of CBT delivered to students by SPs and student mental health outcomes. Secondary and exploratory aims examine cost-effectiveness, moderators, and mechanisms of implementation strategies.MethodsUsing a clustered, sequential multiple-assignment, randomized trial (SMART) design, ≥ 200 SPs from 100 schools across Michigan will be randomized initially to receive REP vs. REP+coaching. After 8 weeks, schools that do not meet a pre-specified implementation benchmark are re-randomized to continue with the initial strategy or to augment with facilitation.DiscussionEBPs need to be implemented successfully and efficiently in settings where individuals are most likely to seek care in order to gain large-scale impact on public health. Adaptive implementation interventions hold the promise of providing cost-effective implementation support. This is the first study to test an adaptive implementation of CBT for school-age youth, at a statewide level, delivered by school staff, taking an EBP to large populations with limited mental health care access.Trial registrationNCT03541317—Registered on 29 May 2018 on ClinicalTrials.gov PRS
Highlights
Depressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes
The study takes advantage of an ongoing initiative to disseminate cognitive behavioral therapy (CBT) training in schools in the State of Michigan, the Transforming Research into Action to Improve the Lives of Students (TRAILS) program
School professional (SP) will be taught through Replicating Effective Programs (REP) to recognize signs of depression and anxiety in students, using public domain screens (Patient Health Questionnaire 9 modified for teens [PHQ-9T] and generalized anxiety disorder [GAD]-7) [51]
Summary
Depressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Less than 20% of youth with depression or anxiety have access to any EBPs, primarily because of limited availability of mental health providers, stigma, and lack of tools to implement effective treatments in the community [7,8,9,10,11,12]. For many individuals with mental health disorders and for youth ages 14 to 21 in particular, non-clinical settings such as schools are attractive options for accessing EBPs [23,24,25] Youth primarily spend their time in schools, which typically have school professionals (SPs) with training in social work, counseling, or psychology and who interface with students on a daily basis [22, 26, 27]. The school professionals with whom they interact rarely have the training or support needed to provide EBPs [29]
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