Increasing Access To Perinatal Mental Health Care: The Perinatal Psychiatry Access Program Model.

Perinatal psychiatry access programs offer a scalable approach to building the capacity of perinatal professionals to identify, assess, and treat mental health conditions. Little is known about access programs' implementation and the relative merits of differing approaches. We conducted surveys and semistructured interviews with access program staff and reviewed policy and procedure documents from the fifteen access programs that had been implemented in the United States as of March 2021, when the study was conducted. Since then, the number of access programs has grown to thirty state, regional, or national programs. Access programs implemented up to five program components, including telephone consultation with a perinatal psychiatry expert, one-time patient-facing consultation with a perinatal psychiatry expert, resource and referral to perinatal professionals or patients, trainings for perinatal professionals, and practice-level technical assistance. Characterizing population-based intervention models, such as perinatal psychiatry access programs, that address perinatal mental health conditions is a needed step toward evaluating and improving programs' implementation, reach, and effectiveness.

The role of perinatal psychiatry access programs in advancing mental health equity.

This editorial presents: 1) a review of Perinatal Psychiatry Access Programs as an integrated care model with potential for promoting perinatal mental health equity; and 2) a summary of how the model has been and can be further adapted to help achieve perinatal mental health equity in geographically diverse settings. Within the editorial, we highlight Access Programs as a promising model for promoting perinatal mental health equity. This editorial is supported by original descriptive data on the Lifeline for Moms National Network of Perinatal Psychiatric Access Programs. Descriptive data is additionally provided on three statewide Access Programs. The Access Program model, and the accompanying Network of Access Programs, is a multi-level approach demonstrating promise in reducing perinatal mental health inequities. Access Programs demonstrate potential to implement interventions to address well-documented inequities in perinatal mental healthcare access at the patient-, clinician-, practice-, community-, and policy-levels. For Access Programs to leverage their potential to advance perinatal mental health equity, systematic efforts are needed that include partnership with impacted communities and implementation teams.

The Role of Formal Policy to Promote Informed Consent of Psychotropic Medications for Youth in Child Welfare Custody: A National Examination.

Active participation of youth and surrogate decision-makers in providing informed consent and assent for mental health treatment is critical. However, the procedural elements of an informed consent process, particularly for youth in child welfare custody, are not well defined. Given calls for psychotropic medication oversight for youth in child welfare custody, this study proposes a taxonomy for the procedural elements of informed consent policies based upon formal and informal child welfare policies and then examines whether enacted state formal policies across the United States endorsed these elements. A sequential multi-method study design included: (1) semi-structured interviews with key informants (n = 58) primarily from state child welfare agencies to identify a taxonomy of procedural elements for informed consent of psychotropic medications and then (2) a legislative review of the 50 states and D.C. to characterize whether formal policies endorsed each procedural element through February 2022. Key informants reported five procedural elements in policy, including how to: (1) gather social and medical history, (2) prescribe the medication, (3) authorize its use through consent and youth assent, (4) notify relevant stakeholders, and (5) routinely review the consenting decision. Twenty-three states endorsed relevant legislation; however, only two states specified all five procedural elements. Additionally, the content of a procedural element, when included, varied substantively across policies. Further research and expert consensus are needed to set best practices and guide policymakers in setting policies to advance transparency and accountability for informed consent of mental health treatment among youth in child welfare custody.

Perspectives on addressing bipolar disorder in the obstetric setting.

OBJECTIVE: Perinatal Psychiatry Access Programs have emerged to help obstetric professionals meet the needs of perinatal individuals with mental health conditions, including bipolar disorder (BD). We elucidate obstetric professionals' perspectives on barriers and facilitators to managing BD in perinatal patients, and how Access Programs may affect these processes. METHODS: We conducted three focus groups with obstetric professionals, two with- and one without-exposure to an Access Program, the Massachusetts Child Psychiatry Access Program (MCPAP) for Moms. Focus groups discussed experiences, barriers, facilitators, and solutions to caring for perinatal individuals with BD. Qualitative data were coded and analyzed by two independent coders; emergent themes were examined across exposure groups. RESULTS: Thirty-one obstetric professionals (7 without-exposure, 24 with-exposure) participated. Identified themes included: (1) gaps in perinatal BD education; (2) challenges in patient assessment; (3) MCPAP for Moms as a facilitator for addressing BD; and (4) importance of continued outreach and destigmaization to increase care collaboration. CONCLUSIONS: Barriers to obstetric professionals accessing adequate mental healthcare for their patients with BD abound. With psychiatric supports in place, it is possible to build obstetric professionals' capacity to address BD. Perinatal Psychiatry Access Programs can facilitate obstetric professionals bridging these gaps in mental health care.

A national survey on adaptations by perinatal psychiatry access programs to promote perinatal mental healthcare equity.

OBJECTIVE: Perinatal Psychiatry Access Programs ("Access Programs") are system-level interventions that aim to build the capacity of perinatal healthcare professionals to address mental health, and thereby improve access to perinatal mental healthcare. Access Programs are widely implemented and positioned to promote health equity in perinatal mental healthcare, but little is known about the adaptations being made to the model in response to calls to promote health equity. METHODS: One respondent from each of the 14 Access Programs (n = 14) completed an online survey that queried on adaptations made to promote perinatal mental healthcare equity. RESULTS: Twelve of the 14 Access Program team members (86%) indicated implementation of at least one new equity initiative. The average number of initiatives that a single Access Program implemented was 3.5 (range 0-10). Two Access Programs (14%) implemented 8.5 initiatives (range: 7-10), indicating that a small cohort is leading promotion of equity among Access Programs. CONCLUSION: Efforts to further expand the capacity and services of Access Programs to address perinatal mental healthcare inequities are needed. These adaptations may provide a robust opportunity for implementation initiatives to promote health equity through a system-level intervention.

A Taxonomy of Reported Harms in Pediatric Autism Spectrum Disorder Screening: Provider and Parent Perspectives.

The U.S. Preventive Services Task Force (USPSTF) report on screening for Autism Spectrum Disorder (ASD) highlighted the need for research that examines the harms potentially associated with screening so as to assess the overall net benefit of universal screening. In response, this study engages qualitative, semi-structured interviews to generate a taxonomy outlining potential harms reported by parents and providers (pediatricians and Early Intervention providers) with experience in screening young children for ASD. Potential harms emerged including: physical, psychological, social, logistical/financial, opportunity cost, attrition, and exacerbation of non-targeted disparities. Respondents reported harms being experienced by the toddlers, parents, and providers. The harms reported highlight opportunities for providers to offer resources that mitigate the potential for these unintended consequences.

Rapid-cycle systems modeling to support evidence-informed decision-making during system-wide implementation.

BACKGROUND: To "model and simulate change" is an accepted strategy to support implementation at scale. Much like a power analysis can inform decisions about study design, simulation models offer an analytic strategy to synthesize evidence that informs decisions regarding implementation of evidence-based interventions. However, simulation modeling is under-utilized in implementation science. To realize the potential of simulation modeling as an implementation strategy, additional methods are required to assist stakeholders to use models to examine underlying assumptions, consider alternative strategies, and anticipate downstream consequences of implementation. To this end, we propose Rapid-cycle Systems Modeling (RCSM)-a form of group modeling designed to promote engagement with evidence to support implementation. To demonstrate its utility, we provide an illustrative case study with mid-level administrators developing system-wide interventions that aim to identify and treat trauma among children entering foster care. METHODS: RCSM is an iterative method that includes three steps per cycle: (1) identify and prioritize stakeholder questions, (2) develop or refine a simulation model, and (3) engage in dialogue regarding model relevance, insights, and utility for implementation. For the case study, 31 key informants were engaged in step 1, a prior simulation model was adapted for step 2, and six member-checking group interviews (n = 16) were conducted for step 3. RESULTS: Step 1 engaged qualitative methods to identify and prioritize stakeholder questions, specifically identifying a set of inter-related decisions to promote implementing trauma-informed screening. In step 2, the research team created a presentation to communicate key findings from the simulation model that addressed decisions about programmatic reach, optimal screening thresholds to balance demand for treatment with supply, capacity to start-up and sustain screening, and availability of downstream capacity to provide treatment for those with indicated need. In step 3, member-checking group interviews with stakeholders documented the relevance of the model results to implementation decisions, insight regarding opportunities to improve system performance, and potential to inform conversations regarding anticipated implications of implementation choices. CONCLUSIONS: By embedding simulation modeling in a process of stakeholder engagement, RCSM offers guidance to realize the potential of modeling not only as an analytic strategy, but also as an implementation strategy.

The decision sampling framework: a methodological approach to investigate evidence use in policy and programmatic innovation.

BACKGROUND: Calls have been made for greater application of the decision sciences to investigate and improve use of research evidence in mental health policy and practice. This article proposes a novel method, "decision sampling," to improve the study of decision-making and research evidence use in policy and programmatic innovation. An illustrative case study applies the decision sampling framework to investigate the decisions made by mid-level administrators when developing system-wide interventions to identify and treat the trauma of children entering foster care. METHODS: Decision sampling grounds qualitative inquiry in decision analysis to elicit information about the decision-making process. Our case study engaged mid-level managers in public sector agencies (n = 32) from 12 states, anchoring responses on a recent index decision regarding universal trauma screening for children entering foster care. Qualitative semi-structured interviews inquired on questions aligned with key components of decision analysis, systematically collecting information on the index decisions, choices considered, information synthesized, expertise accessed, and ultimately the values expressed when selecting among available alternatives. RESULTS: Findings resulted in identification of a case-specific decision set, gaps in available evidence across the decision set, and an understanding of the values that guided decision-making. Specifically, respondents described 14 inter-related decision points summarized in five domains for adoption of universal trauma screening protocols, including (1) reach of the screening protocol, (2) content of the screening tool, (3) threshold for referral, (4) resources for screening startup and sustainment, and (5) system capacity to respond to identified needs. Respondents engaged a continuum of information that ranged from anecdote to research evidence, synthesizing multiple types of knowledge with their expertise. Policy, clinical, and delivery system experts were consulted to help address gaps in available information, prioritize specific information, and assess "fit to context." The role of values was revealed as participants evaluated potential trade-offs and selected among policy alternatives. CONCLUSIONS: The decision sampling framework is a novel methodological approach to investigate the decision-making process and ultimately aims to inform the development of future dissemination and implementation strategies by identifying the evidence gaps and values expressed by the decision-makers, themselves.

Understanding How Parents Make Meaning of Their Child's Behaviors During Screening for Autism Spectrum Disorders: A Longitudinal Qualitative Investigation.

A family's journey in understanding their child's behaviors in relation to Autism Spectrum Disorders (ASD) frequently begins with screening. This study aimed to characterize the interpretive processes that unfold for parents. We employed longitudinal interviews with 19 families engaged in a community-based multi-stage screening protocol. Parents participated in 1-6 interviews dependent upon children's length of engagement in the screening protocol; data were analyzed through modified grounded theory. Parents who moved towards understanding their child's behaviors as ASD expressed (1) sensitization to ASD symptoms, (2) differentiation from other developmental conditions, and (3) use of the ASD diagnosis to explain the etiology of concerning behaviors. Identifying interpretive processes involved during ASD screening provides new opportunities for shared decision-making.

Systematic Review: System-wide Interventions to Monitor Pediatric Antipsychotic Prescribing and Promote Best Practice.

OBJECTIVE: Rapid growth of antipsychotic use among children and adolescents at the turn of the 21st century led Medicaid programs to implement 3 types of system-wide interventions: antipsychotic monitoring programs, clinician prescribing supports, and delivery system enhancements. This systematic review assessed the available evidence base for and relative merits of these system-wide interventions that aim to improve antipsychotic treatment and management. METHOD: Using PRISMA guidelines, eligible studies were written in English and evaluated system-wide interventions to monitor antipsychotic treatment or promote antipsychotic management among children and adolescents (0-21 years of age). Studies were identified through Ovid MEDLINE and PsychInfo (years 1990-2018) and an environmental scan. From an initial review of 824 publications, 17 studies met eligibility criteria. Two authors independently conducted quality assessments using the Crowe Critical Appraisal Tool. Findings were summarized descriptively. RESULTS: Identified studies (n = 17) evaluated prior authorization programs (n = 10), drug utilization reviews (n = 2), quality improvement (n = 4), care coordination programs (n = 1), and multimodal initiatives (n = 2). Studies were predominantly pre-post analyses, without a comparison group. With the exception of care coordination and drug utilization reviews, more than half of the interventions in each category were associated with significant reduction in antipsychotic treatment or promotion of best practice parameters. CONCLUSION: This evidence review concludes that evaluations of prior authorization programs demonstrate reductions in antipsychotic treatment, though evidence of impact of other system-wide interventions and other outcomes is limited. Additional research is necessary to investigate whether interventions influenced antipsychotic prescribing independent of secular trends, the comparative effectiveness and cost-effectiveness of interventions, the effect on functional outcomes, and the potential for unintended consequences.

Multi-method process maps: An interdisciplinary approach to investigate ad hoc modifications in protocol-driven interventions.

INTRODUCTION: Implementation scientists increasingly recognize that the process of implementation is dynamic, leading to ad hoc modifications that may challenge fidelity in protocol-driven interventions. However, limited attention to ad hoc modifications impairs investigators' ability to develop evidence-based hypotheses about how such modifications may impact intervention effectiveness and cost. We propose a multi-method process map methodology to facilitate the systematic data collection necessary to characterize ad hoc modifications that may impact primary intervention outcomes. METHODS: We employ process maps (drawn from systems science), as well as focus groups and semi-structured interviews (drawn from social sciences) to investigate ad hoc modifications. Focus groups are conducted with the protocol's developers and/or planners (the implementation team) to characterize the protocol "as envisioned," while interviews conducted with frontline administrators characterize the process "as realized in practice." Process maps with both samples are used to identify when modifications occurred across a protocol-driven intervention. A case study investigating a multistage screening protocol for autism spectrum disorders (ASD) is presented to illustrate application and utility of the multi-method process maps. RESULTS: In this case study, frontline administrators reported ad hoc modifications that potentially influenced the primary study outcome (e.g., time to ASD diagnosis). Ad hoc modifications occurred to accommodate (1) whether providers and/or parents were concerned about ASD, (2) perceptions of parental readiness to discuss ASD, and (3) perceptions of family service delivery needs and priorities. CONCLUSION: Investigation of ad hoc modifications on primary outcomes offers new opportunities to develop empirically based adaptive interventions. Routine reporting standards are critical to provide full transparency when studying ad hoc modifications.