Public Mental Health Settings Research Articles

Psychotherapists' outcome expectations: How are they established?

Therapists' outcome expectations influence the psychotherapy process and outcomes, but little is known about the factors influencing their development. This study explored therapists' experiences with establishing outcome expectations for their patients. The participants were 35 therapists from a public mental health setting, who were interviewed in five different focus groups. Interviews were transcribed and analyzed using thematic analysis. Three themes and 10 subthemes were identified. In Theme 1 (understanding the problem), participants' expectations were influenced by (a) their patients' diagnoses and the diagnostic process, (b) their perceptions of the complexity of the presenting problem, (c) how stable the patients' symptoms and situations were, and (d) whether they experienced familiarity with the patient or the patients' situation. In Theme 2 (the patient's openness to change), participants' expectations were influenced by (a) the patient's stated reason for seeking treatment, (b) the patient's conceptualization of their problem/situation, and (c) their perception of the patient's willingness to invest in the treatment. In Theme 3 (the fit between the therapist and patient), the participants discussed the factors that influenced whether they felt they were a good fit for working with an individual patient and how this perception of personal and professional fit influenced their expectations. We identify several ways that therapists' situational factors and their recognition of the patient through their own past experiences can influence their expectations. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Metacognitive Therapy for Body Dysmorphic Disorder: A Consecutive Case Series

Background:Research suggests that metacognitions could be important in explaining symptoms of body dysmorphic disorder (BDD), but the effect of metacognitive therapy (MCT) on BDD is unknown.Method:The aim of this consecutive case series was to explore MCT for BDD, delivered individually within a public mental health setting. Treatment was based on MCT manuals for obsessive–compulsive disorder and generalized anxiety disorder. Of 11 eligible participants, 2 declined treatment, 8 completed treatment, and 1 dropped out.Results:MCT for BDD was associated with significant reductions in BDD symptoms, comorbid symptoms of depression and anxiety, and metacognitions. All treatment completers were characterized as treatment responders (i.e., >30% improvement), and improvements were maintained at 3-month follow-up.Conclusions:MCT could be a promising treatment for BDD. Future studies should explore MCT for BDD in controlled trials and explore how to motivate individuals with BDD for psychological treatment.

From plan to practice: A qualitative study of public mental health therapists' session-planning practices.

Therapists must dedicate considerable time to session plan to implement evidence-based practices (EBPs) flexibly and with fidelity. It is unclear whether public mental health settings offer the structural and organizational support for therapists to engage in session planning and, therefore, whether they provide the necessary infrastructure for EBP implementation. In Fall 2022, 18 therapists working in public mental health settings in New York City were recruited through snowball sampling to participate in 90-min semistructured qualitative interviews. Therapists were prompted to review their session-planning practices using a chart-stimulated recall strategy; to describe structural, organizational, and individual barriers and facilitators to session planning; and to generate recommendations to support their session planning. Qualitative data were analyzed using thematic analysis. A diverse group of therapists participated in the study-22% identified as Black; 22% as Asian; and 11% as Hispanic/Latinx. Seventy-eight percent of therapists were social workers; and they had on average 6.18 (SD = 5.70) years of clinical experience. The research team identified four multilevel session-planning barriers and three multilevel session-planning facilitators. Therapists proposed seven multilevel recommendations to support their session planning. Overall, therapists indicated that managing high productivity standards, severe clinical presentations, and clients' social needs often prevent them from having time to plan for sessions. Efforts to implement EBPs in public mental health settings cannot neglect the structural realities faced by agencies, therapists, and clients. Multilevel resources and reforms to support therapists' session planning are necessary. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Investigating Attraction and Retention of Staff Within Public Mental Health Services in Victoria, Australia: Protocol for a Mixed Methods Study.

A large proportion of Australians are affected by mental illness each year, and treatment gaps are well known. To meet current and future demands and enable access to treatment that is safe, effective, and acceptable, a robust and sustainable mental health workforce is required. Factors reported to attract people to work within the mental health sector include aspiring to help others, having an interest in mental health and human behavior, the desire to make a difference and do something worthwhile, personal lived experience, recognition, and value of discipline-specific roles. However, despite the various reasons people enter the public mental health workforce, recruitment and retention continue to be ongoing challenges. To date, there has been limited investigation into understanding which factors are most relevant to the current Victorian workforce. Furthermore, a comparison to health care workers outside of mental health is also needed to better understand the specific needs of staff within the mental health sector. This study aims to explore factors related to attraction, recruitment, and retention of the public mental health workforce in Victoria, Australia. The study is a multisite, mixed methods cross-sectional study to be conducted at 4 public hospital services within Victoria, Australia: 2 in metropolitan and 2 in regional or rural locations. Current, previous, and nonmental health workers will be asked to complete a 20-25-minute web-based survey, which is developed based on previous research and offered participation in an optional 30-60-minute semistructured interview to examine personal experiences and perceptions. Both aspects of the project will examine factors related to attraction, recruitment, and retention in the public mental health workforce. Differences between groups (ie, current, past, and nonmental health workers), as well as location, discipline, and health setting will be examined. Regression analyses will be performed to determine the factors most strongly associated with retention (ie, job satisfaction) and turnover intention. Qualitative data will be transcribed verbatim and thematically analyzed to identify common themes. As of May 2023, we enrolled 539 participants in the web-based survey and 27 participants in the qualitative interview. This project seeks to build on current knowledge from within Australia and internationally to understand role and service/system-related issues of attraction, recruitment, and retention specifically within Victoria, Australia. Seeking up-to-date information from across the health workforce may provide factors specific to mental health by illuminating any differences between mental health workers and health care workers outside of mental health. Furthermore, exploring motivators across health care disciplines and locations to enter, stay in, or leave a role in public mental health settings will provide valuable information to support how the sector plans and develops strategies that are fit for purpose. DERR1-10.2196/48855.

Public mental health and wellbeing interventions delivered by allied health professionals (AHPs): mapping the evidence and identification of gaps. A systematic review

PurposeMental well-being is associated with positive outcomes throughout the life course. This study aims to examine interventions delivered by allied health professionals (AHPs) to alleviate community stressors adversely impacting public mental health and well-being.Design/methodology/approachReview inclusion criteria comprised experimental and qualitative process evaluations of public mental health interventions delivered by AHPs. Electronic searches in Cinahl, Embase, Medline, PsycINFO and the Cochrane Library, were combined with grey literature searches of National Institute for Health and Care Excellence public health guidance. A narrative synthesis and the Effective Public Health Practice Project appraisal tool were used to evaluate the evidence.FindingsA total of 45-articles were included in the review describing AHP-delivered interventions addressing social disadvantage, trauma, bullying, loneliness, work-related stress, transitional stress, intersectionality, pain and bereavement. No articles were identified evaluating interventions delivered by operating department practitioners or orthoptists. A conceptual map was developed summarising the stressors, and a typology of public mental health interventions defined including: place-based interventions, discrete/one-off interventions, multi-component lifestyle and social connector interventions and interventions targeting groups at risk of mental health conditions.Research limitations/implicationsMany mental health conditions begin in childhood, and a strength of the review is the life course perspective. A further strength is compiling a compendium of public mental health outcome measures used by AHPs to inform future research. The authors excluded many articles focussed on clinical interventions/populations, which did not meet review inclusion criteria. While playing a key role in delivering public mental health interventions, clinical psychologists are not defined as AHPs and were excluded from the review, and this may be construed a limitation. Given heterogeneity of study designs and interventions evaluated numerical analyses of pooled findings was not appropriate.Practical implicationsThe review highlights the breadth of community stressors on which AHPs can intervene and contribute in public mental health contexts, stressors which correspond to those identified in UK Government guidance as currently important and relevant to address. The findings can inform developing community public mental health pathways that align with the UK National Health Service (NHS) Long Term Plan, on prevention and early intervention to protect community mental health and well-being. Further can inform the NHS strategic direction for AHPs including informing ways of increasing utilisation of core AHP skills to optimise contributions in public mental health agendas.Social implicationsIt is surprising there were not more AHP delivered evaluations of interventions for other stressors important to address in public mental health settings, for example gambling, domestic violence or that used digital technology, and these are areas for future research. Future research should identify the most active/effective dimensions of multi-component interventions which could be informed by frameworks to guide complex intervention development. The relative paucity of research identified, highlights the predominant focus of research to date on interventions for clinical mental health conditions and populations. The lack of preventative approaches is evident, and an important area for future research to align with UK health and social care priorities.Originality/valueThe review highlights AHP-delivered interventions impacting diverse community stressors across the life course. The findings can inform developing public mental health pathways aligned with government health service priorities to protect mental health and well-being, prioritise prevention and early intervention and increase utilisation of AHP skills across public mental health settings.

A Feasibility Study Investigating Mechanisms of Change in Public Mental Health Dialectical Behaviour Therapy Programmes

AbstractFew studies have investigated the feasibility of researching brief forms of dialectical behaviour therapy (DBT) for borderline personality disorder (BPD) in public mental health settings. This study aimed to provide preliminary evidence for the feasibility of implementing DBT over a 6-month period for BPD symptoms within Australian public mental health services. Of the 79 participants with BPD recruited, 62 commenced and 24 participants completed the therapy. The participants attended one of three outpatient DBT programmes and completed measures of BPD symptoms, DBT skills-use, and difficulties with emotion regulation at baseline and after 6 months of treatment. A major challenge with feasibility identified was the high attrition rate (61%). However, for completers there were significant improvements in BPD symptoms, DBT skills-use, and difficulties with emotion regulation. These effect sizes were used to estimate the sample sizes needed by future larger trials of brief DBT for BPD in public health settings. The implementation of brief DBT for BPD patients within a public mental health outpatient setting, appears to result in significant reductions in BPD symptoms. However, further exploration of strategies to reduce drop-out rates are required.

Development of a novel tool to assess therapists’ alliance through medical clinical reports in public mental health settings

IntroductionMany studies demonstrate that monitoring of the therapeutic alliance can assist therapists to identify changes in patient-therapist relations and accommodate their interventions to prevent early termination. Nonetheless, therapists in public mental health institutes are only required to provide a textual description of patient’s visit, and are usually overloaded to complete empirical measures after each session.ObjectivesThe aim of this study is to develop a novel empirical tool to assess therapists’ perception of the therapeutic alliance through therapists’ clinical reports completed in public mental health.MethodsPatients (N=56) and their therapists (N=32) recruited to participate in a randomized controlled trial completed the Session Alliance Inventory- 6 items (SAI-6) after each session. In this measure, the working alliance included three components: an emotional bond, the agreement on goals, and the agreement on tasks. Afterwards, medical records were extracted and ranked using the SAI-6 by two independent researchers. Inter-rater reliability was .94, indicative of excellent reliability.ResultsOverall, 163 sessions were extracted and evaluated, and were compared with 32 therapist evaluations and 56 patient evaluations. The factor structure of both coders demonstrated a two-factor solution explaining 89.38% of the variance for coder 1, and 71.50% of the variance for coder 2. For patients and therapists, a one-factor solution emerged, explaining 73.00% of the variance for patients, and 62.29% of the variance of the therapists. Both coders demonstrated higher factor loadings of the goals and tasks (0.75-0.81 for coder 1, 0.75-0.78 for coder 2) compared with the bond index (0.57-0.62 for coder 1, 0.52-0.56 for coder 2), indicating higher consistency across these subscales. Internal consistency was alpha Cronbach .87 for coder 1, 0.77 for coder 2, 0.92 for patients and 0.87 for therapists. The scale was partially associated with the therapists’ reports, with coder 2 having a stronger association with therapists ratings in all indexes (r= 0.04 -0.25) than coder 1 (r= 0.03- 0.15). Both coders did not correlate with therapists’ ratings on the bond component. As known in the scientific literature, patients rated the alliance higher than therapists (M=5.74, SD=1.36 for patients, and M=4.67, SD=0.84 for therapists, SE=0.10, p<0.001).ConclusionsThe results of the current study demonstrate the feasibility of assessing therapists’ perceptions of the working alliance via therapists’ routine reports. The differences emerging in the factor structure suggests that coding the clinical reports in primarily beneficial for the evaluation of the agreement on the treatment goals and tasks, and less for the evaluation of patient-therapist emotional bond.Disclosure of InterestNone Declared

Research capacity and culture in an Australian metropolitan public mental health service: scoping the skills and experience of social workers and occupational therapists

BackgroundInvestment in a clinical research culture appears to be associated with benefits for consumers, staff, and overall organisational performance. The validated 55-item Research Capacity and Culture (RCC) tool was developed specifically to gauge the research capacity and culture of health professionals and workplace settings within which they work. Results of some individual studies suggest that professional discipline and workplace setting may impact RCC results however it has never been used in a dedicated public mental health setting. Therefore, this study will explore the research capacity and culture of allied mental health clinicians (Part 1). Another aim is to explore potential connections between workplace settings, locations and disciplines based on published RCC-based data to help signpost potential impediments to service improvements (Part 2).MethodsPart 1: An RCC-based online survey canvased Australian Social Workers and Occupational Therapists (n = 59) based in a metropolitan public mental health service. Non-parametric analyses explored links between research-related experience and participant characteristics.Part 2: Comparative analyses explored the potential influence of workplace settings and professional disciplines on published RCC results.ResultsPart 1: Overall, the research capacity and experiences of mental health Social Workers and Occupational Therapists seemed modest. Discipline was statistically associated with level of research-activity experience, weighted towards occupational therapy; demographic characteristics were not. Only two items in the RCC were rated high; many more items were rated low.Part 2: Published studies exploration found no link between RCC ratings and workplace location, setting, or professional discipline. Sampling biases and use of modified, non-validated RCC versions likely impacted the results.ConclusionsAllied mental health clinicians may not be sufficiently experienced, knowledgeable, or confident with a range of research-related activities given the emphasis on workforce research capability in policy and practice nowadays. This may be commonplace across health-based organisations. We recommend the systematic implementation of research training programs in (mental) health services, and a ‘whole-of-service levels’ approach be used i.e., transform policy, culture and leadership as well as provide practical resources with individual training. Potential benefits include a positive impact on organisation functioning, clinicians’ confidence and practice, and improved consumer outcomes.

From seeing difficult behaviour to recognizing legitimate needs – A qualitative study of mothers' experiences of participating in a Circle of Security Parenting program in a public mental health setting

ABSTRACT Objective Mental health challenges can interfere with caregivers’ self-efficacy and their ability to engage with their children in developmentally appropriate ways. The goal of this study was to explore whether the intervention Circle of Security Parenting (COS-P) was experienced as a meaningful adjunct to psychological treatment. Method Individual qualitative semi-structured interviews were conducted with twelve female COS-P participants, exploring how taking part in COS-P had changed the way they related to themselves and others. Data were analyzed using a team-based, reflexive thematic analysis. Results The analysis resulted in three main themes: (i) Connecting dots: A new perspective on one’s past, (ii) Seeing oneself more clearly: Increased capacity to recognize and tend to own needs, and (iii) Gaining a map: Becoming a more competent parent. Conclusion Taking part in COS-P as an adjunct to psychological treatment positively impacted participants’ sense of competence as mothers. They used the COS-P framework to make sense of their interaction with their child, enabling them to understand the child’s behaviour and communication as expressing legitimate attachment needs. They also experienced that the course strengthened central psychological capacities, such as insight into their own developmental histories as well as increased self-awareness and self-care. Implications are discussed.

Posttraumatic stress disorder and service utilisation outcomes following delivery of Cognitive Processing Therapy in a community mental health setting

ABSTRACT Objective The effectiveness of Cognitive Processing Therapy (CPT) for posttraumatic stress disorder (PTSD) in Australian community mental health settings is understudied as is its impact on other mental health service utilisation. Method Adults (N = 155) with PTSD were seen at a large public health service. PTSD severity was measured at pretreatment, during treatment, and at posttreatment. Additional mental health outcomes and therapeutic processes were indexed (e.g., depression and therapeutic alliance) as was mental health service utilisation by participants in the 12-months prior to and 12-months after receiving CPT. Results Significant improvements across all symptom measures and large effect sizes for PTSD outcomes were observed (Cohen’s d = 1.03–1.66). Analysis of the whole sample (intent-to-treat) demonstrated 46.4% of the sample fell below the probable-PTSD cut-off, and 34.1% achieved remission. On average, participants’ use of mental health services (e.g., inpatient hospitalisations and outpatient services) halved in the 12 months following CPT relative to the same period prior to treatment. No significant adverse outcomes were reported. Conclusion CPT is a safe and effective therapy for PTSD which can be delivered in a routine public mental health setting. Further research should be undertaken to formally establish health cost savings from delivering CPT in the Australian health care system.

The Rising Toll of Public Mental Health Work.

Back to table of contents Next article Taking IssueFull AccessThe Rising Toll of Public Mental Health WorkMark Baptiste, M.D., and Rachel Talley, M.D.Mark BaptisteSearch for more papers by this author, M.D., and Rachel TalleySearch for more papers by this author, M.D.Published Online:1 Jul 2022https://doi.org/10.1176/appi.ps.22073007AboutSectionsPDF/EPUB ToolsAdd to favoritesDownload CitationsTrack Citations ShareShare onFacebookTwitterLinked InEmail Severe mental health workforce shortages and high rates of health care worker burnout have been highlighted as key priority areas to address the U.S. national mental health crisis. Briana S. Last and colleagues (1) present timely findings that underscore the urgency of these priorities. The authors elucidate several facets of the emotional and financial strain experienced by public mental health workers in Philadelphia and demonstrate an inverse association between level of education debt and frequency of evidence-based intervention (EBI) delivery. These findings are alarming but not surprising based on our frontline experience providing clinical care and training in multidisciplinary public mental health settings. Consistent with this study’s findings, we have found that low compensation, high workload driven by volume-based payer incentives, and constant exposure to psychosocially complex and chronically traumatized populations are the ingredients for burnout and high turnover. Despite the best efforts of frontline clinicians and local behavioral health and payer authorities such as those in Philadelphia, these forces can become unsurmountable barriers to sustained uptake of EBIs in settings where they are most needed.Most clinicians in this study needed to work an additional job to supplement their income and carried significant education debt. The authors rightly highlight the crippling effect of low Medicaid reimbursement rates and fee-for-service (FFS) payment models on financial stability and ability to provide appropriate compensation in public mental health settings. Further, FFS financially incentivizes and rewards volume, potentially sacrificing quality. Continuously embedding an EBI can require both initial short-term training/supervision and longer-term, “refresher” venues for training, particularly with staff turnover. In overburdened and understaffed public FFS settings, consistently protecting clinician time for training in EBI is hardly feasible; these tasks compete with the pressure to generate billable encounters. Time and volume demands are uniquely burdensome in public settings because clinicians are charged with applying EBIs from research study conditions to complex populations with multiple comorbid clinical and psychosocial issues. When system financial constraints limit case management access, patients often look to clinicians to assist, further absorbing clinical time. These conditions make the consistent delivery of EBI impossible.Higher rates of reimbursement, increased use of episode-of-care payments with appropriate rates, and increased use of value- and performance-based payment rewarding evidence-based care are critically needed to increase the financial ability of public mental health systems to properly compensate their staff and align payment incentives with delivery of EBI. In addition to these system-level solutions, we applaud Ms. Last and colleagues for suggesting how increased financial resources could be prioritized to directly benefit individual clinicians. We underscore Last and colleagues’ suggestions of compensated ongoing consultation in EBI on the job and wage incentives for use of EBI. Well-intentioned efforts to implement new clinical interventions often do not account for the extra time and energy clinicians require to learn and effectively use these strategies.When a precarious personal financial situation combines with the volume-focused pressure of FFS and the complex conditions of patients in public mental health settings, seeing clinicians experience burnout and secondary stress response is not surprising. High rates of secondary traumatic stress, burnout, and posttraumatic stress disorder in the study’s sample are particularly alarming when coupled with clinician-reported difficulties in affording mental health care. Staff burnout and resultant turnover complicate the ability of public mental health systems to provide consistent long-term provider-patient relationships and care, whether evidence based or not. Beyond the authors’ suggestions of increased peer and supervisory support, benefits covering mental health care and robust employee assistance programs with trauma-informed resources should be considered a mandatory part of trauma-focused EBI intervention, just as is training in the intervention itself. The increased move toward hiring independent contractors removes critical mental health supports for employees.Despite the passion and dedication of frontline public mental health workers, the current financial and emotional toll of their work settings not only stymies sustained uptake of EBI but also threatens the sustainability of this work as a long-term career path. Without significant investment in the financial and emotional well-being of this workforce, we fear a continued migration of talented public mental health clinicians to the private sector.Department of Psychiatry, University of Pennsylvania, Philadelphia.Send correspondence to Dr. Baptiste ([email protected]).Reference1 Last BS, Schriger SH, Becker-Haimes EM, et al.: Economic precarity, financial strain, and job-related stress among philadelphia’s public mental health clinicians. Psychiatr Serv 2022; 73:774–786Abstract, Google Scholar FiguresReferencesCited byDetailsCited ByNone Volume 73Issue 7 July 2022Pages 721-721 Metrics PDF download History Published online 1 July 2022 Published in print 1 July 2022

Identifying Youth Problem Profiles and Predicting Remission Following Mental Health Treatment.

This study utilized latent profile analysis to categorize youth served by a public mental health setting into homogenous classes. Then, associations between class membership and meeting clinical criteria by the latest assessment were examined. Caregiver responses to the Ohio Scales, Short Form, Problem Severity Scale for 1090 youth completed at entry into this public mental health system were subjected to latent profile analysis. This method classifies youth into categories based on mental health problem profiles, in order to determine the degree to which these groupings are related to later mental health outcomes. The classification of youth cases that emerged was then used to predict clinical remission at or nearest end of treatment, including final Ohio Scales Problem Severity scores and a measure of day-to-day functioning, the Child and Adolescent Functional Assessment Scale (CAFAS). A four-class model was identified as best representing the data, reflecting a relatively low-risk class (63.3% of the sample), an internalizing class (23.2%), a delinquency class (8.8%), and a high-risk class (4.7%). Individuals in the internalizing and high-risk classes had lower likelihoods of achieving problem remission than those in the low-risk and delinquencyclasses at the time of their last completed Ohio Scales. Additionally, youth assigned to the delinquency and high-risk classes had lower likelihoods of reaching functional impairment remission than those in theinternalizing and low-risk classes. Youth membership in a class based on initial problem scores can be utilized to predict clinical remission over the course of treatment in public mental health care. Such class-based predictions support other methods of predicting outcomes and can be used by clinicians to develop more informed treatment plans and to adjust treatment based on such classifications.

Using quality improvement methods to improve the effectiveness and sustainability of a social skills intervention for public mental health consumers with psychosis

ABSTRACT Objective While research has shown that psychosocial intervention can improve loneliness and social isolation for adults with psychosis, they are often not routinely offered. This study aimed to learn from consumers to refine a social skill and friendship group (termed “Rel8”) by using Plan-Do-Study-Act (PDSA) quality improvement methodology. This methodology was used to examine the impact of PDSA on intervention implementation and consumer engagement. Methods Mixed-methods were used to compare how engagement, attendance and consumer experience of care changed with two Rel8 groups prior to vs two groups after PDSA-informed changes to content (to address social anxiety and translation of learning) and establishment of a lead therapist. Results Thirty-one consumers commenced Rel8, but completion rates were significantly higher after (83%) than before (42%) PDSA-informed changes to Rel8. Participants found both groups were effective in improving social skills. Conclusion People with psychosis in community mental health services want and benefit from intervention to build social connections. Quality improvement methods that respond to consumers’ feedback and experiences can support programmes to evolve and better meet consumer needs. KEY POINTS What is already known about this topic: People with psychosis want and benefit from psychosocial interventions but these interventions are not routinely offered. Rel8 is an effective, locally adapted program for improving social skills in those with psychosis. Quality improvement processes can be used to enhance implementation, sustainability and the scaling up of evidence-based psychosocial interventions in many healthcare settings.What this topic adds: Incorporating consumer feedback into the implementation and refinement of treatment programs can maximise engagement. Even in resource constrained public mental health settings, quality improvement processes can be used to improve the way evidence-based treatments are designed and delivered. Evidence based social skills focused group interventions are more effective when integrated into the overall care provided, rather than being seen as a stand-alone intervention.

10.G. Workshop: Digital interventions for improving public mental health

Abstract While current routine mental health services provide a range of treatment options for individuals with mental health conditions, specialized support remains difficult to access and tailoring interventions to service users' needs remains challenging. Similarly, the use of, and access to, measures for prevention and mental health promotion continues to be limited, as these are often not tailored to individual needs, preferences, and real-world settings. There is increasing interest in utilizing digital health technologies for improving public mental health provision (i.e., mental health promotion, prevention and treatment of mental disorders) as they allow for adaptive, scalable, real-time, and real-world delivery of intervention components in individuals' daily life. This has driven the development of novel internet-based (eHealth) and app-based mobile health (mHealth) interventions for various mental health outcomes of which ecological momentary interventions (EMIs) represent a powerful approach. To accomplish this, novel research concepts (e.g., living labs) are increasingly being used to develop, optimize, evaluate, and implement digital interventions in routine public mental health provision through a transdisciplinary approach that involves users from the target population and relevant stakeholders throughout the research process to facilitate co-production and lowering barriers of implementation. The workshop's objective is to exemplify the multifaceted use of digital intervention in areas of public mental health and diverse communities and settings. This will include a) novel approaches to modifying continuum beliefs about mental health and an online anti-stigma intervention, b) an EMI to reduce suicide risk among adolescents (EMIRA), c) a self-Help app for Syrian refugees with posttraumatic stress (Sanadak), d) a location-based game to promote (mental) health literacy of adolescents (Nebolus), and e) an artificial intelligence-informed mHealth training for mental health promotion and prevention in adolescents and young adults (AI4U). The discussion will be led by Prof. Steffi Riedel-Heller, MD, MPH, and will focus on the benefits and opportunities afforded by digital technologies in public mental health provision. Key messages Digital interventions signal great promise for improving public mental health. There is a need to carefully evaluate digital interventions before implementation or making them publicly available.

Poor suitability for psychotherapy – a risk factor for treatment non-attendance?

BackgroundPatient suitability has been suggested to predict treatment non-attendance but information on its effect is limited. AimTo study the prediction of the Suitability for Psychotherapy Scale (SPS), on occurrence of treatment non-attendance. MethodsAltogether 326 outpatients, with depressive or anxiety disorder, were randomized to short-term psychodynamic psychotherapy (SPP), long-term psychodynamic psychotherapy (LPP), and solution-focused therapy (SFT). SPS was based on seven components from three suitability domains: nature of problems, ego strength, and self-observing capacity. Treatment non-attendance was defined as refusal of engaging therapy and of premature termination. The Cox model and logistic regression were used. ResultsTreatment non-attendance was significantly more common in LPP patients with poor SPS (RR = 2.76, 95% CI = 1.45-5.26). This was mainly due to poor flexibility of interaction, poor self-concept, and poor reflective ability. Premature termination in SFT showed a similar trend but due to other SPS components: absence of a circumscribed problem, poor modulation of affects, and poor response to trial interpretation. On the contrary, individuals with good values of SPS were more prone to premature termination in SPP. LimitationsThe prediction of suitability on refusal could only be studied in the LPP group due to few refusals in the short-term therapy groups. The sample consisted of patients who participated in a trial. Thus the findings may not be directly generalized to unselected patients in the public mental health setting. ConclusionsPoor suitability, apparently, predicts non-attendance in LPP and SFT, but not in SPP. More studies on large cohorts are needed.

Translating evidence-based psychological interventions for older adults with depression and anxiety into public and private mental health settings using a stepped care framework: Study protocol

BackgroundWith expected increases in the number of older adults worldwide, the delivery of stepped psychological care for depression and anxiety in older populations may improve both treatment and allocative efficiency for individual patients and the health system. DesignA multisite pragmatic randomised controlled trial evaluating the clinical and cost-effectiveness of a stepped care model of care for treating depression and anxiety among older adults compared to treatment as usual (TAU) will be conducted. Eligible participants (n = 666) with clinically interfering anxiety and/or depression symptoms will be recruited from and treated within six Australian mental health services. The intervention group will complete a low intensity cognitive behavioural therapy (CBT) program: Internet-delivered or using a work-at-home book with brief therapist calls (STEP 1). Following STEP 1 a higher intensity face-to-face CBT (STEP 2) will then be offered if needed. Intention-to-treat analyses will be used to examine changes in primary outcomes (e.g. clinician-rated symptom severity changes) and secondary outcomes (e.g. self-reported symptoms severity, health related quality of life and service utilisation costs). An economic evaluation will be conducted using a cost-utility analysis to derive the incremental cost-effectiveness ratio for the stepped care intervention. DiscussionThis study will demonstrate the relative clinical and economic benefits of stepped care model of psychological care for older adults experiencing anxiety and/or depression compared to TAU. The evaluation of the intervention within existing mental health services means that results will have significant implications for the translation of evidence-based interventions in older adult services across urban and rural settings. Trail registrationProspectively registered on anzctr.org.au (ACTRN12619000219189) and isrctn.com (ISRCTN37503850).

Acceptability of and intention to use the Unified Protocol delivered in group format in the Spanish Public Health System.

The high prevalence of emotional disorders leads to a high demand for mental care which results in high costs and long waiting lists in public mental health settings. The Unified Protocol for Transdiagnostic Treatment of Emotional Disorders (UP) is a recent emotion-regulation-based intervention that can be a cost-effective solution in public mental health settings due its transdiagnostic approach and the possibility to apply it in group format. However, the acceptability by mental healthcare professionals (MHCPs) delivering the UP in group format has not been explored. Thirty-three MHCPs, grouped into MHCPs without previous experience and MHCPs with experience in delivering the UP, were asked about aspects of acceptability and intention to use. Quantitative analysis was carried out to explore MHCPs acceptability. Furthermore, qualitative opinion about UP were collected through a SWOT (strengths, weaknesses, opportunities, threats) analysis to explore MHCPs opinion of delivering the UP intervention in a group format, within the Spanish Public Mental Health System. The results showed high scores in all acceptability dimensions and intention to use in the future. SWOT analysis showed strengths and opportunities focusing on its transdiagnostic nature and the cost-effective benefits of group treatment, and weaknesses and threats related to the limited material and human resources. Findings indicate high acceptability of the UP by MHCPs working within the Spanish Public Mental Health System and also identified areas for improvements. In order to enhance the dissemination and implementation of the UP, it is essential to consider MHCPs' perceptions and to be open to their suggestions.

Using behavioral insights to design implementation strategies in public mental health settings: a qualitative study of clinical decision-making

BackgroundTrauma-focused cognitive behavioral therapy (TF-CBT) is an evidence-based intervention for youth with posttraumatic stress disorder. An important component of TF-CBT is the trauma narrative (TN), a phase in the intervention in which youth are guided to process the memories, thoughts, and feelings associated with their traumatic experience(s). Previous work has shown that TF-CBT clinicians complete TNs with only half of their clients, yet little is known about what determines TF-CBT clinicians’ use of TNs. The behavioral insights literature—an interdisciplinary field studying judgment and decision-making—offers theoretical and empirical tools to conceptualize what drives complex human behaviors and decisions. Drawing from the behavioral insights literature, the present study seeks to understand what determines clinician use of TNs and to generate strategies that target these determinants.MethodsThrough semi-structured qualitative interviews, we sought the perspectives of trained TF-CBT clinicians working in public mental health settings across the city of Philadelphia (N = 17) to understand their decisions to use TNs with clients. We analyzed the qualitative data using a coding approach informed by the behavioral insights literature. We used an iterative process of structured hypothesis generation, aided by a behavioral insights guide, and rapid validation informed by behavioral insights to uncover the determinants of TN use. We then generated implementation strategies that targeted these determinants using the “Easy Attractive Social Timely” framework, a behavioral insights design approach.ResultsWe generated and validated three broad themes about what determines clinician implementation of TNs: decision complexity, clinician affective experience, and agency norms. We hypothesized behavioral insights that underlie these implementation determinants and designed a list of nine corresponding behavioral insights strategies that may facilitate TN implementation.ConclusionsOur study investigated why an effective component of an evidence-based intervention is difficult to implement. We leveraged robust scientific theories and empirical regularities from the behavioral insights literature to understand clinician perspectives on TN implementation. These factors were theoretically linked to implementation strategies. Our work revealed the potential for using behavioral insights in the diagnosis of evidence-based intervention determinants and the design of implementation strategies.

Organizational Capacity and Readiness to Provide Medication for Individuals with Co-Occurring Alcohol Use Disorders in Public Mental Health Settings.

Alcohol use disorders (AUD) in individuals with mental illness are largely untreated. The purpose of this study was to identify gaps in organizational capacity and readiness to provide medications for AUD in outpatient public mental health clinics. We selected a purposive sample of eight publicly funded outpatient mental health clinics operated by the Los Angeles County Department of Mental Health; clinics were chosen to maximize heterogeneity. Guided by theories of organizational capacity and readiness and research on the adoption of pharmacotherapy for AUD in primary and specialty care treatment settings, we conducted semi-structured interviews and focus groups with administrators, providers and staff, and a qualitative analysis of the results. Respondents described significant organizational capacity and behavioral readiness constraints to providing medication treatment for AUD. Both groups articulated a perception that mental health clinics were not designed to provide co-occurring AUD treatment because of large caseloads, staffing configurations, and time constraints that did not support the delivery of appropriate treatment, and a lack of protocols and workflow procedures. We documented organizational capacity and readiness constraints which impede the delivery of medication treatment for AUD in a large mental helth system. While some constraints have straightforward solutions, others require structural changes to the way care is delivered, and state-level funding and policy changes.

Does Adding the Dialectical Behavior Therapy Prolonged Exposure (DBT PE) Protocol for PTSD to DBT Improve Outcomes in Public Mental Health Settings? A Pilot Nonrandomized Effectiveness Trial With Benchmarking

The Dialectical Behavior Therapy Prolonged Exposure (DBT PE) protocol improves DBT’s effects on PTSD in research settings, but its effectiveness in community settings is largely unknown. This pilot nonrandomized controlled trial examined DBT with and without DBT PE in four public mental health agencies. Patients (N = 35, 12-56 years old, 80.0% female, 64.7% racial/ethnic minorities, 44.1% sexual minorities) had PTSD, were receiving DBT, and completed assessments every four months over one year. Sixteen patients (45.7%) initiated DBT PE, 19 (54.3%) did not, and dropout did not differ between groups (31.3% vs. 26.3%). The primary barrier to initiating DBT PE was clinician turnover (57.9% of non-initiators). After adjusting for confounds, DBT PE initiators (g = 1.1) and completers (g = 1.4) showed a greater reduction in PTSD than patients who received DBT only (g = 0.5; p’s < .05). Rates of reliable improvement in PTSD were 71.4% (DBT PE completers), 53.8% (DBT PE initiators), and 31.3% (DBT). Similar patterns were observed for posttraumatic cognitions, emotion dysregulation, general psychological distress, and limited activity days. There was no worsening of self-injurious behavior or crisis service use among patients who received DBT PE. Benchmarking analyses indicated comparable feasibility, acceptability, and safety, but a smaller magnitude of clinical change, than in efficacy studies. Results require replication in a randomized trial but suggest that DBT PE can be transported effectively to community settings.