Implementing trauma-focused cognitive behavioral therapy in Philadelphia: A 10-year evaluation.

Background: In 2012, Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS) developed an initiative to implement an evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health system. This report evaluates the initiative's 10-year implementation and effectiveness outcomes. Method: The Exploration, Preparation, Implementation, and Sustainment framework guided our implementation evaluation. The implementation outcomes include adoption, reach, and sustainment; these were obtained during regular evaluation data collection from publicly funded behavioral health agencies participating in the TF-CBT initiative. We analyze effectiveness outcomes (i.e., changes in PTSD symptoms) from a subset of patients receiving TF-CBT, which were collected in 6-month intervals by our research team between 2013 and 2021. Results: From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for potentially traumatic events and PTSD symptoms, and 7,550 youths received TF-CBT. Through the TF-CBT initiative, the city expanded the network of TF-CBT providers from 3 to 20 agencies. DBHIDS sustained this network by maintaining the participation of 16 behavioral health agencies over the course of a decade. The subset of 202 youths who were evaluated to assess TF-CBT effectiveness was drawn from 94 therapists and 20 agencies across Philadelphia. All participating youths completed a baseline assessment, and 151 (75%) completed at least one follow-up assessment. Linear mixed-effects models accounting for observations nested within participants and nested within clinicians found that treatment significantly reduced PTSD symptoms. Conclusion: Between 2012 and 2021, DBHIDS successfully implemented and sustained TF-CBT across the city's behavioral health system. Adoption, reach, and sustainment of TF-CBT were high. Despite the considerable adverse experiences faced by youths seeking treatment in Philadelphia's behavioral health system, TF-CBT was effective. Future directions to improve TF-CBT implementation in the next iteration of the initiative are described.

This practical implementation report describes a 10-year effort by the city of Philadelphia to develop a trauma-informed behavioral health system, making this report one of the longest evaluations of an implementation initiative in a large metropolitan area in the United States. In particular, the report describes the implementation and effectiveness outcomes of Philadelphia's Department of Behavioral Health and Intellectual disAbility Services (DBHIDS)'s implementation of the evidence-based treatment for posttraumatic stress disorder (PTSD), trauma-focused cognitive behavioral therapy (TF-CBT), across the city's behavioral health agencies. From 2012 to 2021, DBHIDS trained 478 clinicians in TF-CBT across 20 behavioral health agencies. During this time, 23,401 youths were screened for posttraumatic stress symptoms, and 7,550 youths received TF-CBT. A subset of 202 youths receiving TF-CBT from 94 therapists across 20 Philadelphia agencies were evaluated to assess the initiative's effectiveness. Linear mixed-effects models revealed that youths receiving TF-CBT from DBHIDS-trained clinicians saw their PTSD symptoms significantly reduce. The initiative's success in adoption, reach, sustainment, and effectiveness reveals the promise of sustained, multipronged, community-partnered implementation initiatives. In the future, researchers and policymakers must account for and address the structural and financial barriers that hinder these community-partnered implementation efforts from realizing their full potential in improving population health.

Striving for Equity in Community Mental Health: Opportunities and Challenges for Integrating Care for BIPOC Youth.

Supporting the mental health of youth who identify as Black, Indigenous, or Persons of Color (BIPOC) continues to be a challenge for clinicians and policymakers alike. Children and adolescents are a vulnerable population, and for BIPOC youth, these vulnerabilities are magnified by the effects of structural, interpersonal, and internalized racism. Integration of psychiatric care into other medical settings has emerged as an evidence-based method to improve access to psychiatric care, but to bridge the gap experienced by BIPOC youth, care must extend beyond medical settings to other child-focused sectors, including local governments, education, child welfare, juvenile legal systems, and beyond. Intentional policy decisions are needed to incentivize and support these systems, which typically rely on coordination and collaboration between clinicians and other stakeholders. Clinicians must be trauma-informed and strive for structural competency to successfully navigate and advocate for collaborative systems that benefit BIPOC youth.

Understanding therapists' perceived determinants of trauma narrative use.

BACKGROUND: Trauma narratives are a critical, exposure-based component of trauma-focused cognitive-behavioral therapy, yet community therapists rarely use them. Given evidence that intentions to deliver elements of cognitive behavioral therapy vary by component, and that intentions to deliver exposure are the weakest, this study focused specifically on trauma narratives. We drew on a social psychology causal theory (Theory of Planned Behavior (TPB)) and an implementation science framework (the Consolidated Framework for Implementation Research (CFIR)) to glean insight into multilevel influences on trauma narrative use. While the CFIR offers a broad list of factors potentially affecting implementation, the TPB offers causal pathways between individual-level constructs that predict behavior, including the uptake of an evidence-based intervention. The integration of these approaches may provide a more complete understanding of factors affecting therapists' use of TNs. METHODS: Therapists (n=65) trained in trauma-focused cognitive behavioral therapy completed a survey about their use of and beliefs about trauma narratives. Content analysis was used to identify common beliefs about trauma narratives. A subset of participants (n=17) completed follow-up qualitative interviews, which were analyzed using an integrated approach informed by the CFIR. RESULTS: While most participants reported high intentions to use TNs, nearly half reported that they did not use TNs in the last 6 months. Survey data indicate a number of TPB-related determinants related to using trauma narratives. Qualitative interviews identified CFIR-relevant contextual factors that may influence constructs central to TPB. CONCLUSIONS: These results highlight the importance of integrating approaches that address multiple theoretical determinants of therapist behavior, including therapist, organizational, and client factors with causal explanations to explain implementation behavior.

Accentuate the Positive: Strengths-Based Therapy for Adolescents.

PURPOSE: The field of psychiatry has conventionally employed a medical model in which mental health disorders are diagnosed and treated. However, the evidence is amassing that using a strengths-based approach that promotes wellness by engaging the patient's assets and interests may work in synergy with the medical model to promote recovery. This harmonizes with the patient-centered care model that has been promoted by the Institute of Medicine. METHODS: The article uses a clinical case to highlight the attributes of a strength-based model in the psychiatric treatment of adolescents. RESULTS: Outcome metrics from a number of studies have demonstrated enhanced youth and parent satisfaction and decreased use of hospital level of care with the implementation of strengths-based therapeutic modalities. IMPLICATIONS: Incorporating strengths-based interventions into conventional psychiatric practice provides a multi-faceted treatment approach that promotes recovery in children and adolescents with psychiatric disorders.

Sociodemographic characteristics of youth in a trauma focused-cognitive behavioral therapy effectiveness trial in the city of Philadelphia.

While randomized controlled trials of trauma-focused cognitive behavioral therapy (TF-CBT) have demonstrated efficacy for youth with posttraumatic stress disorder, TF-CBT effectiveness trials typically show attenuated outcomes. This decrease in effectiveness may be due to the differences in sociodemographic characteristics of youth in these trials; youth in efficacy trials are more often white and middle-income, whereas youth in effectiveness trials are more often racial/ethnic minorities, of low socioeconomic status (SES) and live in high crime neighborhoods. In this study-drawn from an effectiveness trial of TF-CBT in community mental health clinics across Philadelphia-we describe the sociodemographic characteristics of enrolled youth. We measured neighborhood SES by matching participants' addresses to American Community Survey data from their Census tracts, housing stability using the National Outcomes Measurement System, and neighborhood violence using police department crime statistics. Our results suggest that the majority of youth presenting for TF-CBT in mental health clinics in the City of Philadelphia live in poor and high-crime neighborhoods, experience substantial housing instability, and are predominantly ethnic and racial minorities. Thus, youth presenting for treatment experience significant racial and socioeconomic adversity. We also explored the association between these characteristics and youth symptom severity upon presenting for treatment. These factors were not associated with youth symptom severity or overall mental health functioning in our sample (with small effect sizes and p > .05 for all). Implications for future research, such as the need for efficacy and effectiveness trials to more fully characterize their samples and the need for pragmatic trials are discussed.

Correction to: A repeated cross-sectional study of clinicians' use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia.

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Benchmarking Treatment Effectiveness of Community-Delivered Trauma-Focused Cognitive Behavioral Therapy.

It is critical for urban youth with post-traumatic stress disorder (PTSD) living in poverty to have access to evidence-based interventions for their traumatic stress. However, there is limited research on the effectiveness of these interventions when provided in urban, community settings. The objectives of the current study are to (a) evaluate the effectiveness of trauma-focused cognitive behavioral therapy delivered from 2013 to 2016 in 15 behavioral health agencies on youth (N = 114) PTSD as well as  general mental health symptoms and  functioning, and (b) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health System, a system that has invested significantly in the training and ongoing support of clinicians providing high-quality trauma services to youth since 2012. From baseline to last assessment, youth PTSD symptom severity (d = 0.34), PTSD functional impairment (d = 0.38), and overall mental health problem severity (d = 0.29) improved. The effect sizes of  improvements were smaller than effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF-CBT and provides preliminary findings with regard to the effectiveness, and transportability, of TF-CBT to urban community settings that serve youth in poverty.

A repeated cross-sectional study of clinicians' use of psychotherapy techniques during 5 years of a system-wide effort to implement evidence-based practices in Philadelphia.

BACKGROUND: Little work investigates the effect of behavioral health system efforts to increase use of evidence-based practices or how organizational characteristics moderate the effect of these efforts. The objective of this study was to investigate clinician practice change in a system encouraging implementation of evidence-based practices over 5 years and how organizational characteristics moderate this effect. We hypothesized that evidence-based techniques would increase over time, whereas use of non-evidence-based techniques would remain static. METHOD: Using a repeated cross-sectional design, data were collected three times from 2013 to 2017 in Philadelphia's public behavioral health system. Clinicians from 20 behavioral health outpatient clinics serving youth were surveyed three times over 5 years (n = 340; overall response rate = 60%). All organizations and clinicians were exposed to system-level support provided by the Evidence-based Practice Innovation Center from 2013 to 2017. Additionally, approximately half of the clinicians participated in city-funded evidence-based practice training initiatives. The main outcome included clinician self-reported use of cognitive-behavioral and psychodynamic techniques measured by the Therapy Procedures Checklist-Family Revised. RESULTS: Clinicians were 80% female and averaged 37.52 years of age (SD = 11.40); there were no significant differences in clinician characteristics across waves (all ps > .05). Controlling for organizational and clinician covariates, average use of CBT techniques increased by 6% from wave 1 (M = 3.18) to wave 3 (M = 3.37, p = .021, d = .29), compared to no change in psychodynamic techniques (p = .570). Each evidence-based practice training initiative in which clinicians participated predicted a 3% increase in CBT use (p = .019) but no change in psychodynamic technique use (p = .709). In organizations with more proficient cultures at baseline, clinicians exhibited greater increases in CBT use compared to organizations with less proficient cultures (8% increase vs. 2% decrease, p = .048). CONCLUSIONS: System implementation of evidence-based practices is associated with modest changes in clinician practice; these effects are moderated by organizational characteristics. Findings identify preliminary targets to improve implementation.

Lessons learned while building a trauma-informed public behavioral health system in the City of Philadelphia.

Exposure to traumatic experiences among youth is a serious public health concern. A trauma-informed public behavioral health system that emphasizes core principles such as understanding trauma, promoting safety, supporting consumer autonomy, sharing power, and ensuring cultural competence, is needed to support traumatized youth and the providers who work with them. This article describes a case study of the creation and evaluation of a trauma-informed publicly funded behavioral health system for children and adolescents in the City of Philadelphia (the Philadelphia Alliance for Child Trauma Services; PACTS) using the Exploration, Preparation, Implementation, and Sustainment (EPIS) as a guiding framework. We describe our evaluation of this effort with an emphasis on implementation determinants and outcomes. Implementation determinants include inner context factors, specifically therapist knowledge and attitudes (N=114) towards evidence-based practices. Implementation outcomes include rate of PTSD diagnoses in agencies over time, number of youth receiving TF-CBT over time, and penetration (i.e., number of youth receiving TF-CBT divided by the number of youth screening positive on trauma screening). We describe lessons learned from our experiences building a trauma-informed public behavioral health system in the hopes that this case study can guide other similar efforts.

Radiation Monitoring Results from the First Year of Operation of a Unique Ambulance-based Computed Tomography Unit for the Improved Diagnosis and Treatment of Stroke Patients.

When a blood clot blocks the blood supply to the brain or when a blood vessel bursts, resulting in brain cell death, the medical condition is referred to as a "stroke." Stroke is a main cause of death worldwide and is a common cause of disability. A common form of stroke, called ischemic stroke, is when blood flow to the brain is decreased. Clinical research has revealed that treatment within the very first hours of symptom onset is key for ischemic stroke with recanalization of occluded arteries by thrombolysis with alteplase. Computed tomography (CT) is one of the diagnostic tools used to determine if this treatment path is appropriate. To determine if health outcomes of possible stroke patients can be improved by decreasing the time from symptom presentation to treatment, the first mobile stroke ambulance unit in the United States was deployed by The University of Texas Health Science Center at Houston (UTHealth) in 2014, equipped with a computed tomography imaging system. The mobile stroke unit shortens the time to treatment for stroke patients by allowing pre-hospital treatment. Having completed its first year of operation, radiation-monitoring data describing the doses delivered to various entities have been characterized. The CT operator's cumulative deep dose equivalent for 1 y of operation was 1.14 mSv resulting from the care of 106 patients. Area monitors were deployed and measurements performed demonstrating that general public doses did not exceed 0.02 mSv h⁻¹ or 1.0 mSv year.

Independent Contractors in Public Mental Health Clinics: Implications for Use of Evidence-Based Practices.

OBJECTIVES: Community mental health clinics are increasingly utilizing independent contractors to provide clinical services. At the same time, many organizations are participating in initiatives intended to increase implementation of evidence-based practices (EBPs). The primary aim of this study was to understand the associations of utilizing independent contractors with clinician knowledge and attitudes toward EBPs and organizational culture and climate. The study also sought to understand the potential impact of using independent contractors on mental health services delivery from the perspective of organizational leadership. METHODS: Quantitative data were collected from 130 therapists in 23 organizations; qualitative data were collected from executive administrators in nine of the 16 organizations participating in EBP initiatives sponsored by the City of Philadelphia. Regression with random effects was used to estimate the associations between worker status (contractor or employee) and clinician attitudes toward EBPs, knowledge of EBPs, and organizational culture and climate. Qualitative inquiry was used to understand the impact of reliance on independent contractors on organizational participation in EBP initiatives. RESULTS: Independent contractors endorsed less positive attitudes toward EBPs and scored lower on knowledge of EBPs. Interviews revealed four main themes: reasons for using independent contractors, general consequences of using independent contractors, specific impact of independent contractors on participation in EBP initiatives, and suggestions for alternatives. CONCLUSIONS: A growing number of community mental health clinics rely on independent contractors. There may be consequences of this shift that deserve exploration.

Benefits of Stroke Treatment Using a Mobile Stroke Unit Compared With Standard Management: The BEST-MSU Study Run-In Phase.

BACKGROUND AND PURPOSE: Faster treatment with intravenous tissue-type plasminogen activator (tPA) is likely to improve outcomes. Optimizing prehospital triage by mobile stroke units (MSUs) may speed treatment times. The Benefits of Stroke Treatment Delivered Using a Mobile Stroke Unit (BEST-MSU) study was launched in May 2014 using the first MSU in the United States to compare stroke management using an MSU versus standard management (SM). Herein, we describe the results of the prespecified, nonrandomized run-in phase designed to obtain preliminary data on study logistics. METHODS: The run-in phase consisted of 8 MSU weeks when all-patient care occurred on the MSU and 2 SM weeks when the MSU nurse met personnel on scene or at the emergency department to ensure comparability with MSU patients. Telemedicine was independently performed in 9 MSU cases. RESULTS: Of 130 alerts, 24 MSU and 2 SM patients were enrolled. Twelve of 24 MSU patients received tPA on board; 4 were treated within 60 minutes of last seen normal, and 4 went on to endovascular treatment. There were no hemorrhagic complications. Four had primary intracerebral hemorrhage. Agreement on tPA eligibility between the onsite and telemedicine physician was 90%. CONCLUSIONS: The run-in phase provided a tPA treatment rate of 1.5 patients per week, assured us that treatment within 60 minutes of onset is possible, and enabled enrollment of patients on SM weeks. We also recognized the opportunity to assess the effect of the MSU on endovascular treatment and intracerebral hemorrhage. Challenges include the need to control biased patient selection on MSU versus SM weeks and establish inter-rater agreement for tPA treatment using telemedicine.

Establishing the first mobile stroke unit in the United States.

BACKGROUND AND PURPOSE: Recently, the Mobile Stroke Unit (MSU) concept was introduced in Germany demonstrating prehospital treatment of more patients within the first hour of symptom onset. However, the details and complexities of establishing such a program in the United States are unknown. We describe the steps involved in setting up the first MSU in the United States. METHODS: Implementation included establishing leadership, fund-raising, purchase and build-out, knitting a collaborative consortium of community stakeholders, writing protocols to ensure accountability, radiation safety, purchasing supplies, licensing, insurance, establishing a base station, developing a communication plan with city Emergency Medical Services, Emergency Medical Service training, staffing, and designing a research protocol. RESULTS: The MSU was introduced after ≈1 year of preparation. Major obstacles to establishing the MSU were primarily obtaining funding, licensure, documenting radiation safety protocols, and establishing a smooth communication system with Emergency Medical Services. During an 8 week run-in phase, ≈2 patients were treated with recombinant tissue-type plasminogen activator per week, one-third within 60 minutes of symptom onset, with no complications. A randomized study to determine clinical outcomes, telemedicine reliability and accuracy, and cost effectiveness was formulated and has begun. CONCLUSION: The first MSU in the United States has been introduced in Houston, TX. The steps needed to accomplish this are described.

Free, brief, and validated: Standardized instruments for low-resource mental health settings.

Evidence-based assessment has received little attention despite its critical importance to the evidence-based practice movement. Given the limited resources in the public sector, it is necessary for evidence-based assessment to utilize tools with established reliability and validity metrics that are free, easily accessible, and brief. We review tools that meet these criteria for youth and adult mental health for the most prevalent mental health disorders to provide a clinical guide and reference for the selection of assessment tools for public sector settings. We also discuss recommendations for how to move forward the evidence-based assessment agenda.

Increased expression of P-glycoprotein is associated with doxorubicin chemoresistance in the metastatic 4T1 breast cancer model.

Development of drug resistance is one of the major causes of breast cancer treatment failure. The goal of this study was to understand the chemoresistance mechanism using the highly metastatic 4T1 breast cancer model, which emulates stage IV breast cancer in humans. The metastatic 4T1 breast cancer cell line treated with either doxorubicin or 5-FU showed a concentration-dependent reduced cell proliferation, with induced G2-phase growth arrest (doxorubicin) or G1-phase growth arrest (5-FU). Doxorubicin treatment partially suppressed the multiorgan metastasis of 4T1 breast cancer cells in the lung, heart, liver, and bone, compared with either 5-FU or cyclophosphamide. We isolated and characterized 4T1 breast cancer cells from doxorubicin-resistant metastatic tumors (cell line 4T1-R). Multiorgan metastasis of drug-resistant 4T1 breast tumors was totally resistant to doxorubicin treatment. Our results indicate that doxorubicin is localized exclusively in the cytoplasm of resistant 4T1 breast cancer cells and that it cannot reach the nucleus because of increased nuclear expression of P-glycoprotein. Pretreatment of doxorubicin-resistant 4T1-R breast cancer cells with verapamil, a general inhibitor of P-glycoprotein, increased nuclear translocation of doxorubicin and cellular cytotoxicity. Thus, impaired nuclear translocation of doxorubicin due to increased expression of P-glycoprotein is associated with doxorubicin resistance of highly metastatic 4T1 breast cancer.