Standardizing Fidelity to Evidence-Based Practice in the Early Psychosis Intervention Network.

OBJECTIVE: This study investigated variations in the measurement of fidelity to coordinated specialty care (CSC) within the Early Psychosis Intervention Network (EPINET), a learning health system that consists of 101 CSC programs within eight hubs. The study investigated the degree to which five fidelity scales could be mapped onto a standard scale. METHODS: The investigators identified six fidelity scales in use by EPINET participants; examined their item content, scoring, and data sources; and mapped five scales onto the First Episode Psychosis Services Fidelity Scale (FEPS-FS), which is the most widely used scale. RESULTS: Mapping five fidelity scales onto the FEPS-FS showed that the percentage of FEPS-FS components successfully mapped ranged from 42% to 81%. CONCLUSIONS: Mapping five scales onto one that uses dichotomous scoring identified the degree of variation in measures and reduced the amount and quality of usable fidelity data. Identifying variations in fidelity measurement is a core function of a learning health system.

Antibullying Interventions in Schools: Assessing the Evidence Base.

OBJECTIVE: This systematic review used established rating criteria to describe the level of evidence for interventions aimed at preventing or reducing bullying perpetration and victimization in schools, synthesized the evidence for students from racially and ethnically diverse backgrounds, and reviewed the literature for available information to conduct an economic analysis of the interventions. METHODS: Major databases, gray literature, and evidence-base registries were searched to identify studies published from 2008 through 2022. The authors rated antibullying intervention models as having high, moderate, or low evidence depending on the number and rigor of studies with positive findings. RESULTS: Overall, 80 articles reporting on 71 original research studies describing a total of 48 antibullying interventions met the inclusion criteria for this review. Two schoolwide interventions received a high-evidence rating: the KiVa (Kiusaamista Vastaan) Antibullying Program and the Friendly Schools program. Multilevel interventions with components at the levels of school, classroom, and individual student most consistently showed strong evidence for reducing bullying behavior in elementary and middle school grades. Four interventions yielded positive effects in reducing bullying and victimization among diverse samples of students. CONCLUSIONS: Antibullying interventions can reduce bullying in schools. Some interventions show effectiveness with students from racially and ethnically diverse backgrounds. The gains relative to per-student costs were in the range that is considered cost-effective. Most implementation costs are spent on staff training and support. Research on successful implementation of whole-school interventions and additional synthesis of evidence pertaining to program structures would further advance the antibullying evidence base.

Assessing the Evidence Base for School-Based Promotion and Prevention Interventions: Introduction to the Series.

Schools are an important component in the mental health system of care for youths. Teachers and other school staff have unique opportunities to promote emotional wellness and prevent mental health conditions. Although numerous programs are available, identifying evidence-based and effective options is a significant challenge. This introduction lays out the rationale and methodology of the Assessing the Evidence Base (AEB) Series, a collection of systematic reviews of school-based mental health promotion and prevention approaches recommended by the National Academies of Sciences, Engineering, and Medicine for students in kindergarten through grade 12. Authors of the current AEB Series used the rating criteria derived from the 2014 AEB Series, which provided systematic reviews of a wide spectrum of interventions for mental and substance use disorders. Like its predecessor, the current series upholds a high standard of scientific rigor while ensuring that the information is easily accessible to various stakeholders in education, behavioral health, and communities. It describes the universal features included in each systematic review, such as a rating of the level of evidence for interventions, intervention program components, identification of interventions that have yielded positive outcomes for students from underserved populations, and a review of cost data. The AEB systematic reviews will serve as an important tool for decision makers involved in managing limited resources for various programs in school-based mental health services by synthesizing large bodies of research for use by leaders in education and behavioral health.

Reducing Disruptive and Distracting Behaviors in the Classroom: Assessing the Evidence Base.

OBJECTIVE: Disruptive and distracting behaviors in the classroom, from off-task to aggressive behaviors, negatively affect academic engagement and achievement and can lead to more serious problems, including mental health conditions and substance use disorders. The goals of this systematic review were to assess the level of evidence, using established rating criteria, for interventions aimed at preventing or reducing disruptive and distracting classroom behaviors; identify program components common to multiple interventions; synthesize the evidence in regard to students from different racial-ethnic groups; and conduct an economic analysis of these interventions. METHODS: A search of major databases, gray literature, and evidence base registries was conducted to identify studies published between 2008 and 2022. The authors rated interventions as having high, moderate, or low levels of evidence of effectiveness on the basis of the number and rigor of studies with positive outcomes. RESULTS: Of the 27 interventions identified across 65 studies (N=73 articles), six interventions received a high or moderate evidence rating. The Good Behavior Game was the most frequently studied intervention. Many interventions shared similar program components, including behavioral management, classroom management, emotional-cognitive processes, and skills acquisition. Most articles (86%) were focused on elementary school students. The four interventions rated as having high evidence of effectiveness also showed generally positive outcomes in studies conducted in school settings with racial-ethnic diversity. No studies met the criteria for inclusion in an economic analysis. CONCLUSIONS: With greater use and more research, interventions focusing on reducing disruptive and distracting behaviors have the potential to promote student well-being and prevent mental health conditions.

The Effectiveness of Interventions Intended to Improve Employment Outcomes for Persons with Substance Use Disorder: An Updated Systematic Review.

BACKGROUND: Employment is one of the strongest predictors of positive outcomes for persons with substance use disorder. Purpose: To conduct a systematic review of interventions intended to improve employment outcomes for persons with substance use disorder (SUD) at any stage of recovery. This is an update of a prior review published in 2004. Methods: Two bibliographic databases, PUBMED and PSYCHINFO, were searched for articles published in the period 2005-2018 that referenced employment, education, or vocational rehabilitation for people with SUD. Results: One hundred thirty-two articles were identified of which 14 met the criteria for inclusion, primarily a minimum of a quasi-experimental evaluation design. Each study was reviewed with the following format: setting (modality); subject characteristics; research procedures; results; limitations/comments. Results: Nine programs or models were represented among the 14 studies, with Individual Placement and Pupport (IPS) and its variant Customized Employment Supports (CES) having the most studies with positive results. But generally, the magnitude of any intervention effects on employment was small for all interventions; one outcome may have shown statistical significance while one or more other outcomes did not, and there was little consistency in how outcomes were measured among the studies. Conclusions/Importance: IPS/CES currently shows the most evidentiary support. But all the studies of interventions with positive outcome data should be replicated with larger samples in diverse settings.

Screening for Behavioral Health Conditions in Primary Care Settings: A Systematic Review of the Literature.

BACKGROUND: Mounting evidence indicates that early recognition and treatment of behavioral health disorders can prevent complications, improve quality of life, and help reduce health care costs. The aim of this systematic literature review was to identify and evaluate publicly available, psychometrically tested tools that primary care physicians (PCPs) can use to screen adult patients for common mental and substance use disorders such as depression, anxiety, and alcohol use disorders. METHODS: We followed the Institute of Medicine (IOM) systematic review guidelines and searched PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Cumulative Index to Nursing and Allied Health Literature, and Health and Psychosocial Instruments databases to identify literature addressing tools for screening of behavioral health conditions. We gathered information on each tool's psychometrics, applicability in primary care, and characteristics such as number of items and mode of administration. We included tools focused on adults and the most common behavioral health conditions; we excluded tools designed for children, youth, or older adults; holistic health scales; and tools screening for serious but less frequently encountered disorders, such as bipolar disorder. RESULTS: We identified 24 screening tools that met the inclusion criteria. Fifteen tools were subscales stemming from multiple-disorder assessments or tools that assessed more than one mental disorder or more than one substance use disorder in a single instrument. Nine were ultra-short, single-disorder tools. The tools varied in psychometrics and the extent to which they had been administered and studied in primary care settings. DISCUSSION: Tools stemming from the Patient Health Questionnaire had the most testing and application in primary care settings. However, numerous other tools could meet the needs of primary care practices. This review provides information that PCPs can use to select appropriate tools to incorporate into a screening protocol.

Permanent supportive housing: assessing the evidence.

OBJECTIVES: Permanent supportive housing provides safe, stable housing for people with mental and substance use disorders who are homeless or disabled. This article describes permanent supportive housing and reviews research. METHODS: Authors reviewed individual studies and literature reviews from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. The authors chose from three levels of evidence (high, moderate, and low) on the basis of benchmarks for the number of studies and quality of their methodology. They also described the evidence of service effectiveness. RESULTS: The level of evidence for permanent supportive housing was graded as moderate. Substantial literature, including seven randomized controlled trials, demonstrated that components of the model reduced homelessness, increased housing tenure, and decreased emergency room visits and hospitalization. Consumers consistently rated this model more positively than other housing models. Methodological flaws limited the ability to draw firm conclusions. Results were stronger for studies that compared permanent supportive housing with treatment as usual or no housing rather than with other models. CONCLUSIONS: The moderate level of evidence indicates that permanent supportive housing is promising, but research is needed to clarify the model and determine the most effective elements for various subpopulations. Policy makers should consider including permanent supportive housing as a covered service for individuals with mental and substance use disorders. An evaluation component is needed to continue building its evidence base.

Supported employment: assessing the evidence.

OBJECTIVE: Supported employment is a direct service with multiple components designed to help adults with mental disorders or co-occurring mental and substance use disorders choose, acquire, and maintain competitive employment. This article describes supported employment and assesses the evidence base for this service. METHODS: Authors reviewed meta-analyses, research reviews, and individual studies from 1995 through 2012. Databases surveyed were PubMed, PsycINFO, Applied Social Sciences Index and Abstracts, Sociological Abstracts, Social Services Abstracts, Published International Literature on Traumatic Stress, the Educational Resources Information Center, and the Cumulative Index to Nursing and Allied Health Literature. Authors chose from three levels of evidence (high, moderate, and low) based on benchmarks for the number of studies and quality of their methodology. They also described the evidence for service effectiveness. RESULTS: The level of research evidence for supported employment was graded as high, based on 12 systematic reviews and 17 randomized controlled trials of the individual placement and support model. Supported employment consistently demonstrated positive outcomes for individuals with mental disorders, including higher rates of competitive employment, fewer days to the first competitive job, more hours and weeks worked, and higher wages. There was also strong evidence supporting the effectiveness of individual elements of the model. CONCLUSIONS: Substantial evidence demonstrates the effectiveness of supported employment. Policy makers should consider including it as a covered service. Future research is needed for subgroups such as young adults, older adults, people with primary substance use disorders, and those from various cultural, racial, and ethnic backgrounds.

Key factors for implementing supported employment.

OBJECTIVE: This study examined strategies and barriers for implementing supported employment in routine mental health services. METHODS: Qualitative and fidelity data from a two-year period (2002-2004) were examined for nine sites participating in the National Evidence-Based Practices Project. RESULTS: At baseline, none of the sites were providing high-fidelity supported employment. However, by the two-year follow-up, eight of the nine sites successfully implemented high-fidelity programs. Three factors, leadership, mastery, and attitudes, were identified as strongly influencing the implementation (both positively and negatively) across the nine sites. CONCLUSIONS: The findings indicate the need for strong leadership on both the administrative and program levels, an in-depth understanding of the nature and level of training and consultation needed for program leaders and employment specialists, and the value of hiring staff with clinical or business skills. The study also demonstrated that employing staff who doubt and challenge the evidence-based model slows down the implementation process, suggesting the critical role of hiring staff who believe in recovery and supported employment principles.

Unmet needs of families of adults with mental illness and preferences regarding family services.

OBJECTIVE: This study used a survey to assess the information and educational needs of family members of adults with mental illness and their preferences regarding how to address those needs. METHODS: Recruitment was attempted through two sources: local mental health treatment facilities and the Maryland chapter of the National Alliance on Mental Illness (NAMI). Inadequate contact information and low response rate produced only 16 responses from family members of consumers recruited through local mental health facilities. Thus results are reported for a family needs assessment survey mailed to NAMI members (308 of 962 possible responses). Bivariate and multivariate analyses were used to summarize relationships between characteristics of the family member, characteristics of the ill relative, experience of stigma by the family member, and information needs of the family members. RESULTS: On average, family members reported a substantial number of unmet needs (mean+/-SD of 7.09+/-4.71 needs; possible number of needs ranges from 0 to 16), often despite prior receipt of information. Family members' experiences of stigma and having an ill relative with a more recently occurring condition (for example, a younger relative or a shorter length of illness) or with a disabling condition (for example, recent hospitalization) were significantly associated with a greater number of unmet needs. Family members preferred that a mental health provider (63%) address their needs on an as-needed basis (58%). CONCLUSIONS: The needs and preferences of family members of adults with mental illness are diverse and varied. Consequently, these families may benefit from ongoing provision of information and support tailored to meet the families' individual needs. Continued efforts should be made to understand and address consumer and family needs, potential barriers to participation in family services, and the relationship between stigma and family need.

Provider contact with families of adults with severe mental illness: taking a closer look.

This exploratory study examined the frequency and nature of providers' contact with families of persons with severe mental illness. Fifty-nine providers in six community mental health programs completed a self-administered survey. A subsample of 8 providers also completed two in-depth interviews. Although most providers had some family contact, the contact was restricted to a small percent of their caseloads. The nature of contact that providers have with families is generally limited by their professional role. Best practice guidelines for the treatment of mental illness and agency administrators responsible for instituting these guidelines will need to clarify the types of providers who are expected to implement various aspects of family involvement.

Professionals' responsibilities in releasing information to families of adults with mental illness.

OBJECTIVE: Statutes, ethical standards, and local confidentiality guidelines have been developed to guide providers' decisions about releasing information from mental health records. However, confidentiality policies often do not specifically discuss the release of confidential information to the families of persons with mental illness. This study examined how providers and family members interpret and implement confidentiality policies about the release of information to families. METHOD: S: Self-administered surveys were completed by 59 providers from outpatient, partial hospitalization, and case management programs in Pennsylvania. In-depth interviews were also conducted with a subsample of eight providers. In addition, 68 families of persons with mental illness receiving services from these providers completed self-administered surveys. RESULTS: Ninety-five percent of the providers interpreted confidentiality policies conservatively, believing that they could not share confidential information without the consent of the client, However, 54 percent were confused about the types of information that are confidential. Implementation of confidentiality policies varied among the providers. Regression analysis indicated that providers' perceptions of confidentiality as a barrier to collaboration were significantly associated with their attitudes toward collaboration between the providers, consumers, and family members. Few families understood the requirements of confidentiality policies or the types of information that are confidential. CONCLUSION: S: Confidentiality policies may be posing a barrier to collaboration between providers, consumers, and family members, which has been recommended by various experts for the treatment of mental illness. Clear guidelines for the release of confidential information to families are needed.

Provider and family beliefs regarding the causes of severe mental illness.

The study examined mental health providers' and families' of adults with severe mental illness beliefs regarding the etiology of mental illness. A countywide sample of 87 providers and family members was collected over a course of six months as part of a consensus building process to institute family education. Beliefs regarding the biological basis of mental illness are not replacing family causation beliefs for providers and families. Instead, providers and families hold biological and family causation theories regarding the etiology of mental illness simultaneously. Providers with less family contact were more likely to believe that families may cause mental illness, when controlling for race, gender, education, and years working in mental health. Families with negative provider experience are also more likely to hold family causation beliefs, when controlling for race, gender, and education. Further research is needed to explore the effects of provider and family beliefs regarding the etiology of mental illness on provider-family contact and collaboration.

The APA classification of mental disorders: future perspectives.

After 8-10 years of experience with the fourth edition of the Diagnostic and Statistical Manual (DSM-IV) and the tenth edition of the International Classification of Diseases (ICD-10), it is an ideal time to begin looking at the clinical and research consequences of these diagnostic systems. The American Psychiatric Association, in conjunction with the National Institutes of Health, has initiated a research development process intended to accelerate an evaluation of existing criteria while developing and testing hypotheses that would improve the validity of our diagnostic concepts. Over the past year, a multidisciplinary, international panel has developed a series of six white papers which define research opportunities in the following broad areas: Nomenclature, Disability and Impairment, Personality Disorders, Relational Disorders, Developmental Psychopathology, Neuroscience, and Cross-Cultural aspects of Psychopathology. Recommendations for future national and international research in each of these areas will be discussed.