Implementation of a Telemental Health Training Program Across a Mental Health Department.

Introduction: Telemental health (TMH) has increased substantially. However, health care systems have found it challenging to implement TMH ubiquitously. A quality improvement project guided by implementation science methodology was used to design and implement a TMH training program. Materials and Methods: Implementation science methodology (Promoting Access to Research Implementation in Health Services, Reach-Effectiveness-Adoption-Implementation-Maintenance, Implementation/Facilitation) provided the framework to design and implement the training program. A total of 100 interdisciplinary mental health providers from outpatient mental health clinics participated. Results: Providers reported satisfaction with the training program. Results indicated that the training increased providers' TMH knowledge and competence. The number of providers using TMH and patients who received TMH nearly doubled. Conclusions: Implementation science methodology was important in creating an organizational framework at this facility to design, evaluate, and implement an innovative TMH training program.

Identifying and addressing mental health providers' perceived barriers to clinical video telehealth utilization.

OBJECTIVE: Clinical video telehealth (CVT) is an innovative modality to provide care directly to Veterans' homes. Despite prior training initiatives, CVT remains underutilized. This project sought to better understand barriers to implementation and to compare responses of CVT utilizers versus nonutilizers. METHOD: Mental health staff were invited to complete an online anonymous survey on their use of CVT in clinical practice. RESULTS: A total of 159 mental health staff completed the survey. Although the majority of the sample endorsed personal use of a video chat program, less than half reported using CVT for patient care. Among nonutilizers, lack of training was the most frequently endorsed barrier to CVT use whereas administrative burden was the most frequently endorsed barrier by utilizers. CONCLUSIONS: This study extends existing literature by determining barriers to CVT adoption. It identifies several barriers among utilizers versus nonutilizers. Discussion includes potential guidelines for overcoming barriers to CVT utilization.

Telemental health training in the Veterans Administration Puget Sound Health Care System.

As a pioneer of training in the field of psychology, the Veterans Affairs (VA) HealthCare System serves as a leader in the training in and provision of Telemental Health (TMH) services in the United States. To meet goals toward continued expansion of these services, the VA TMH training program includes both web-based didactic courses and a skills competency test at a basic level with supervision and consultation in TMH for more advanced training and is available to staff psychologists and psychologist trainees. Despite these efforts, barriers for training in and implementation of TMH occur at the provider, system, and patient level. At the national level, the VA is actively working to resolve these barriers and we share site-specific examples implemented by the VA Puget Sound Health Care System promoting access through TMH team to further address barriers to training and implementation.

Recommendations for Using Clinical Video Telehealth with Patients at High Risk for Suicide.

There is increasing evidence that the delivery of mental health services via clinical video telehealth (CVT) is an effective means of providing services to individuals with access barriers, such as rurality. However, many providers have concerns about working with individuals at risk for suicide via this modality, and many clinical trials have excluded individuals with suicide risk factors. The present article reviews the literature, professional guidelines, and laws that pertain to the provision of mental health services via CVT with high-risk patients and provides suggestions for adapting existing best-practice recommendations for assessing and managing suicide risk to CVT delivery.

The efficacy of Focused Acceptance and Commitment Therapy in VA primary care.

Focused Acceptance & Commitment Therapy (FACT) is a brief intervention based on traditional Acceptance and Commitment Therapy (ACT). Although there is a growing body of research on the efficacy of ACT for a variety of populations and disorders, there is little research to date on the use of FACT in group settings. This project is 1 of the first of its kind, as it examines data on psychological flexibility, health and mental health status, and symptom reduction from a 4-week FACT group. Participants in this study were 51 patients who attended this group as part of routine clinical care in a VA integrated primary care and mental health setting. They completed pre- and posttreatment measures of well-being, depression, anxiety, stress, psychological flexibility, and perceptions of physical and mental health functioning. Pre- to posttreatment analyses of variance demonstrated large effects for quality of life, F(1, 51) = 21.29, p < .001, η2 = 0.30, moderate effects for depressive symptoms, F(1, 51) = 11.47, p < .001, η2 = 0.08, and perceptions of mental health functioning (MCS scale), F(1, 51) = 9.67, p = .003, η2 = 0.11, and small effects for perceptions of perceived stress, F(1, 51) = 4.08, p = .04, η2 = 0.03, and physical health functioning (PCS scale), F(1, 51) = 6.60, p = .01, η2 = 0.08. There was a statistical trend for reductions in anxiety, F(1, 51) = 3.29, p = .07, η2 = 0.01, and a nonsignificant effect for psychological flexibility, F(1, 51) = 2.05, p = .16, η2 = 0.04. These data provide initial support for the implementation of a group-based FACT protocol within a VA primary care setting and help to lay a foundation for further, more controlled studies on Group FACT in future research. (PsycINFO Database Record

MPI profile classifications and associated clinical findings among litigating motor vehicle collision patients.

OBJECTIVES: The purpose of this study was to examine differences in precollision, pericollision, and postcollision clinical variables across litigating motor vehicle collision (MVC) patients who were classified as Dysfunctional (DYS), Interpersonally Distressed (ID), or Adaptive Copers (ACs) based on Multidimensional Pain Inventory (MPI) profile classifications. MATERIALS AND METHODS: A sample of 240 MVC patients who sustained serious physical injuries and experienced MVC-related chronic pain completed the MPI and provided responses to a semistructured psycholegal interview designed to elicit injury-related and pain-related symptoms and treatments, determine the presence and impact of precollision experiences, and render psychiatric diagnoses and ratings of psychological disability. RESULTS: A significant multivariate effect of MPI profile group on postcollision variables was revealed, with the DYS and ID groups reporting more pain sites than the AC group and the DYS group receiving more recommendations for treatment than the AC group. Larger proportions of the DYS and ID groups were diagnosed as experiencing major depressive disorder than the AC group. A rating of total psychological disability was applied most often to members of the ID group, with partial psychological disability applied most often to members of the DYS group, and no psychological disability applied most often to members of the AC group. DISCUSSION: This study extends the MPI literature by establishing the usefulness of the measure in determining those reports of MVC-related pain and emotional distress that are most likely to be associated with postcollision psychological disability. The current study supports the usefulness of MPI profile classifications in identifying MVC patients who are likely to require and benefit from intensive psychological and other rehabilitative interventions.

A unifying hypothesis of schizophrenia: abnormal immune system development may help explain roles of prenatal hazards, post-pubertal onset, stress, genes, climate, infections, and brain dysfunction.

We propose a unifying hypothesis of schizophrenia to help reconcile findings from many different disciplines. This hypothesis proposes that schizophrenia often involves pre- or perinatal exposure to adverse factors that produce a latent immune vulnerability. When this vulnerability is manifested, beginning around puberty with changes in immune function and involution of the thymus, individuals become more susceptible to infections and immune dysfunctions that contribute to schizophrenia. Our hypothesis suggests theoretical bridges between different lines of evidence on schizophrenia and offers explanations for many puzzling findings about schizophrenia. For example, the hypothesis helps account for why schizophrenia patients tend to have had increased exposure to neurotropic infections, but most individuals with such exposure do not develop schizophrenia, and why prenatal hardships increase risk for schizophrenia, but the onset of symptoms typically does not occur until after puberty. The hypothesis also explains another paradox: lower socioeconomic status and poor prenatal care increase risk for schizophrenia at the same geographic site, but international comparisons indicate that countries with higher per capita incomes and better prenatal care actually tend to have higher schizophrenia prevalences. As the hypothesis predicts, (1) prenatal adversity, which increases risk for schizophrenia, also impairs post-pubertal immune competence, (2) schizophrenia patients experience elevated morbidity from infectious and auto-immune diseases, (3) genetic and environmental risk factors for schizophrenia increase vulnerability to these diseases, (4) factors that exacerbate schizophrenic symptoms also tend to impair immune function, (5) many anti-psychotic medications combat infection, (6) effects of early infections may not appear until after puberty, when they can produce neurologic and psychiatric symptoms, and (7) immune dysfunctions, such as imbalances of pro- and anti-inflammatory cytokines, may contribute to the onset of psychotic symptoms and the progressive loss of brain tissue in schizophrenia. The disruptive effects of prenatal adversity on the development of the immune system may often combine with adverse effects on prenatal brain development to produce schizophrenia. This paper focuses on the adverse immune system effects, because effects on the brain have been extensively discussed in neurodevelopmental theories of schizophrenia. We propose new tests of scientific predictions. We also point out potential clinical implications of the hypothesis; for example, individuals with schizophrenia may often have underlying infections or immune dysfunctions, such as imbalances in inflammatory cytokines, that contribute to the illness. This possibility could be tested experimentally--e.g., by clinical trials in which patients' exposure to infection is reduced or immune function is normalized.