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“The implementation gap prevents our nation from reaping the benefit of billions of US tax dollars spent on research and, more important, prolongs the suffering of millions of Americans who live with mental disorders.”—President's New Freedom Commission on Mental Health 2003. Despite the development of effective treatments, depression is still ranked as one of the top ten causes of disability worldwide according to the World Health Organization. It often takes years if not decades to translate evidence-based depression treatments into nonacademic, community-based practices. This research-to-practice gap can lead to millions of dollars of funded research being wasted when the treatments themselves never reach the populations in need [1]. Without a clear strategy to foster implementation and acceptance at the community provider level, a “voltage drop” is experienced when an evidence-based depression treatment developed in tightly-controlled academic settings is then introduced into real-world settings [2]. Moreover, current clinical trials populations are still highly selective (<5% of the diagnosed population) despite the movement towards “community-based research.” There is a paucity of effective strategies or implementation approaches for getting effective treatments for depression and other mental disorders off the academic shelf and into the hands of those who need them. Subsequently, there is a need for further cross-disciplinary research on effective processes to facilitate the uptake of evidence-based treatments in real-world practices. Implementation science is an emerging field poised to address the organizational, provider, and patient-level barriers to the adoption of new treatments for depression as well as for other conditions. The National institute of Mental Health defines implementation as the “use of strategies to adopt and integrate evidence-based health interventions and change practice patterns within specific settings [3].” This current issue explores novel approaches based on implementation science for enhancing the uptake of depression treatments. The articles address a range of concepts, both at a higher level on tools for and theories of effective implementation and at the practical level of lessons learned on the ground. This series of articles also focuses on implementing evidence-based programs to improve depression outcomes particularly for underserved populations including lower income patients, adolescents, and women with postpartum depression. Four articles describe the application of implementation theory and measures to inform changes in mental health practice in general and for depression treatment in particular. J. K. Benzer et al. describe barriers and facilitators to coordinated mental health care in primary care settings. Key findings were used to refine an implementation theory for coordinated depression care included the importance of organizational factors such as resources, provider training and workflow designs, and an understanding and appreciation of mental health and primary care practice boundaries. Two additional articles describe complementary approaches for engaging providers in the implementation of new mental health treatments. E. Aisenberg et al. describe a process for building a community-academic partnership to implement telephone cognitive-behavioral therapy for rural Latinos. The article points to how such partnerships can facilitate the adaptation of evidence-based practices in community settings by garnering frontline participant feedback on which elements need to be changed to implement a more scalable and culturally appropriate program. Similarly, D. E. Goodrich et al., using the Enhanced Replicating Effective Programs implementation framework, describe the implementation of an outreach program for Veterans with mental disorders, and what lessons were learned in regards to activating and empowering providers to “lead from the middle” and work within their systems to facilitate patient access. In addition, the paper by A. J. Lewis et al. describes how qualitative data can be applied to develop fidelity and implementation measures to assess update of a family-focused depression intervention. Providers are key stakeholders in the implementation process, yet few studies have focused on the development of effective implementation strategies to facilitate provider training in and sustainability of using evidence-based depression treatments. Three of the papers in this special issue address the challenges in training clinicians in new mental health treatments, and whether training leads to long-term adoption and use of these practices, in particular, problem-solving therapy (PST). J. A. Cartreine et al. describe a web-based training program to further disseminate PST training to novice clinicians and whether long-term coaching by more experienced providers to further boost training effectiveness might be needed. In the paper by R. M. Crabb et al., clinicians undergoing training in PST were followed over to assess the long-term impact of the training on adoption and spread. S. W. Stirman et al. identified key reasons for variation in cognitive behavioral therapy training outcomes across community-based practices and the importance of garnering feedback from frontline providers prior to implementing training initiatives. Additional studies in this issue involved the implementation of depression treatments, notably in real-world populations. J. A. Waxmonsky et al. found that implementing a depression chronic care management programs in a public sector health plan led to significantly reduced depression severity over a 12-month period with a modest increase in health care costs. R. R. Dopp et al. present results of a novel program for adolescents with depression, demonstrating an alternative way to address mood symptoms that in turn also address other major chronic conditions such as obesity. Finally, B. P. Yawn et al. present a systematic review of postpartum depression treatment programs in which the most effective components included formal psychiatric evaluation, colocation of mental health care, and tracking of long-term outcomes. Ultimately, implementation science can inform the adoption and adaptation of effective depression treatments, primarily through a better understanding of the importance of building partnerships with end-users such as health care organizations and frontline providers, understanding barriers to adoption of effective treatments at these levels, and developing interventions that use organizational strategies such as collaborative care or systematic training programs to facilitate adoption. Moreover, there will be additional opportunities for researchers and practitioners to apply the lessons learned from this emerging field to develop more effective and practical depression treatments from the beginning, as well as the use of provider and health care organization-level strategies to ensure their adoption and sustainability in the real world. To this end, new skills will need to be acquired, including the measurement of factors facilitating or impeding treatment uptake, especially at the provider and system level using both qualitative and quantitative methods, application of nonrandomized controlled study designs that take into account variations in provider and organizational differences, as well as the inclusion of real-world patient populations that to date are not well-represented in depression clinical trials. Moreover, by placing greater emphasis on partnerships, frontline provider input, and practical treatment strategies, mental health implementation researchers will be poised to lead the development of the next generation of effective depression treatments. Amy M. Kilbourne Mark Williams Mark S. Bauer Patricia Arean
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1Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence
Perceived Effectiveness of Medications Among Mental Health Service Users With and Without Alcohol Dependence
263Perceived Stigma and Mental Health Care Seeking
There is limited empirical evidence on the extent to which perceived public stigma prevents individuals from using mental health services, despite substantial recent policy interest in this issue. This study investigated associations between perceived public stigma and mental health care seeking. This study used cross-sectional survey data from a representative sample of undergraduate and graduate students (N=2,782) at one university. A five-item scale was used to assess perceived public stigma toward mental health service use. Perceived need for help in the past 12 months and current presence of depressive and anxiety disorders were also assessed. Perceived stigma was higher among males, older students, Asian and Pacific Islanders, international students, students with lower socioeconomic status backgrounds, and students with current mental health problems. Perceived stigma was also higher among those without any family members or friends who had used mental health services and among those who believed that therapy or medication is not very helpful. Perceived stigma was negatively associated with the likelihood of perceiving a need for mental health services, but only among younger students. Among those with probable depressive or anxiety disorders, there was no evidence that perceived stigma was associated with service use. These results suggest that, at least in this population, perceived stigma may not be as important a barrier to mental health care as the mental health policy discourse currently assumes.
Read more125Enhancing Pediatric Mental Health Care: Strategies for Preparing a Primary Care Practice
In 2004, the American Academy of Pediatrics (AAP) Board of Directors formed the Task Force on Mental Health and charged it with developing strategies to improve the quality of child and adolescent mental health* services in primary care. The task force acknowledged early in its deliberations that enhancing the mental health care that pediatricians and other primary care clinicians† provide to children and adolescents will require systemic interventions at the national, state, and community levels to improve the financing of mental health care and access to mental health specialty resources. Systemic strategies toward achieving these improvements are the subject of other publications of the task force: “ Strategies for System Change in Children's Mental Health: A Chapter Action Kit ” (chapter action kit),1 “Improving Mental Health Services in Primary Care: Reducing Administrative and Financial Barriers to Access and Collaboration,”2 and “Enhancing Pediatric Mental Health Care: Strategies for Preparing a Community.”3 The task force also recognized that enhanced mental health practice will require competencies not currently achieved by many primary care clinicians; in the policy statement “The Future of Pediatrics: Mental Health Competencies for Pediatric Primary Care,”4 the task force collaborated with the AAP Committee on Psychosocial Aspects of Child and Family Health to outline these competencies and propose strategies for achieving them. This report offers strategies for preparing the primary care practice itself for provision of enhanced mental health care services. The task force proposes incrementally applying chronic care principles to the care of children with mental health and substance abuse problems as primary care clinicians apply them to the care of children with chronic medical conditions such as asthma. Most primary care clinicians will find that significant gaps exist between their current practice and the proposed ideal. The task force offers guidance in … Address correspondence to Jane Meschan Foy, MD, Department of Pediatrics, Wake Forest University School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157. E-mail: jmfoy{at}wfubmc.edu
Read more11Meso-level Comparison of Mental Health Service Availability and Use in Chile and Spain
Meso-level Comparison of Mental Health Service Availability and Use in Chile and Spain
Talbott and Financing Policy: Reducing Fragmentation
Talbott and Financing Policy: Reducing Fragmentation
Association Between Receipt of Mental Health Care and Substance Use in Adults With Depression and Unmet Treatment Needs
<h3>Context</h3> More than nine million adults have a co-occurring mental illness and a substance use disorder (SUD), and the rate of these co-occurring disorders (CODs) has steadily increased. Unmet need for mental health care may lead individuals to self-medicate with alcohol or drugs. Some research suggests that rural populations experience higher unmet mental health care needs and lower access to treatment, potentially leading to self-medication. <h3>Objective</h3> To examine the association between receipt of mental health care, geographic location and subsequent substance use among adults with past-year depression who reported an unmet need for treatment. <h3>Study Design and Analysis</h3> We conducted a pooled cross-sectional analysis using logistic regression models with interaction terms to evaluate the relationship between treatment receipt, geographic location, and past 30-day substance use. <h3>Dataset</h3> National Survey on Drug Use and Health (NSDUH), 2015–2018. <h3>Population Studied</h3> Adults aged ≥18 years with stated past-year major depressive episode and a reported unmet need for mental health care. <h3>Intervention/Instrument</h3> Self-reported receipt of inpatient, outpatient, and/or prescription medication treatment for mental health conditions in the past year. <h3>Outcome Measures</h3> Past 30-day use of alcohol, marijuana, illicit drugs, and the misuse of prescription drugs. <h3>Results</h3> Among 5,803 adults with unmet mental health needs, receipt of any mental health care was associated with lower odds of heavy drinking (OR=0.54, 95% CI: 0.29–1.00). Logistic regression revealed that, compared to large metro areas, those in small metro (OR=3.02, 95% CI: 1.30–7.00) and nonmetro (OR=4.76, 95% CI: 1.50–15.06) areas who received care had higher odds of heavy drinking; small metro residents also had higher odds of marijuana use (OR=1.91, 95% CI: 1.18–3.10). <h3>Conclusions</h3> Mental health treatment among adults with depression and a stated unmet need for mental health care may reduce heavy alcohol use overall, but effects vary by location, with some rural and small metro residents exhibiting higher substance use despite care. These findings suggest that limited access to comprehensive, high-quality mental health services—particularly outside metropolitan areas—may leave needs insufficiently addressed, leading to continued self-medication. Policymakers and providers should prioritize expanding access to integrated, effective mental health and substance use treatment in underserved rural areas.
Read more9Psychotherapy Update for the Practicing Psychiatrist: Promoting Evidence-Based Practice
The last three decades have witnessed significant advances in psychotherapy. Numerous scholarly articles and books have been devoted to pertinent topics in the field, making it difficult for the practicing clinician to keep up with this rapidly growing area. The purpose of this article is to provide some guidelines on how to evaluate the empirical literature in psychotherapy and then to explore three key areas: evidence-based psychotherapies for patients with psychiatric disorders, individual variables that predict differential outcome to treatment, and the therapeutic alliance. Finally, two case examples will be presented to illustrate how knowledge of the empirical literature can facilitate an evidence-based approach to the daily practice of psychotherapy in general psychiatry.
Read more6Guideline-Consistent Antidepressant Treatment Patterns Among Veterans With Diabetes and Major Depressive Disorder
Guideline-Consistent Antidepressant Treatment Patterns Among Veterans With Diabetes and Major Depressive Disorder
16County-Level Estimates of Need for Mental Health Professionals in the United States
County-Level Estimates of Need for Mental Health Professionals in the United States
3Mental Health Policy and Services Five Years After the President's Commission Report: An Interview With Michael F. Hogan
Mental Health Policy and Services Five Years After the President's Commission Report: An Interview With Michael F. Hogan
7Improving Medication Management of Depression in Health Plans
Improving Medication Management of Depression in Health Plans
1Experts Outline Costs, Barriers To High-Quality Depression Treatment
Experts Outline Costs, Barriers To High-Quality Depression Treatment
63A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"
Individuals with serious mental illness often are unable to access consumer- and family-oriented community care, resulting in repeated hospitalizations, incarceration, and homelessness. The "medical home" concept was developed in primary care to provide accessible and accountable services for individuals with chronic medical conditions. Building on the work done in primary care, the authors propose a "mental health home." The model of care incorporates medical home characteristics, such as access to and coordination of services, integration of primary and preventive care, adoption of recovery orientation and evidence-based practices, and family and community outreach. Barriers to and strategies for implementation of mental health homes are discussed.
Read more8A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"
A New Kind of Homelessness for Individuals With Serious Mental Illness? The Need for a "Mental Health Home"
32Premixed vs basal-bolus insulin regimen in Type 2 diabetes: comparison of clinical outcomes from randomized controlled trials and real-world data.
To evaluate the concordance between data derived from randomized controlled trial (RCT) and real-world estimates of HbA1c and weight change after 24 weeks of initiation of a basal-bolus compared with a premixed insulin regimen in people with Type 2 diabetes. Data eight RCTs were pooled after a systematic review of studies examining basal-bolus (n = 1893) or premixed (n = 1517) regimens. Real-world data were extracted from the UK primary care dataset for people on basal-bolus (n = 7483) or premixed insulin regimens (n=10 744). The mean differences between HbA1c and weight from baseline were calculated using t-tests, while analysis of variance was used to compare the two treatment regimens. Linear regression analyses were used to determine the predictors of this change. Both insulin regimens were associated with HbA1c reductions (real-world data -0.28%; RCT data, -1.4%) and weight gain (real-world data, +0.27 kg; RCT data, +2.96 kg) but there were no significant differences between basal-bolus and premixed insulin. Discordances in the pattern of treatment response were observed, however, between real-world and RCT data for both insulin regimens. For any given baseline HbA1c concentration, the change in HbA1c in the RCTs was greater than in real-world conditions and for those with baseline weight above ~60 kg, RCT data showed overall weight gain in contrast to slight weight loss in the real-world population. Lastly, for both randomized controlled trial and real-world populations, while greater baseline weight was associated with reduced response to treatment, the association was much steeper in the RCT than in the real-world population. In addition, greater baseline weight was associated with greater weight reductions in both premixed insulin and basal-bolus insulin regimens, although to a lesser extent with the latter. These results highlight specific discrepancies in the HbA1c reduction and weight change in insulin regimen between real world versus RCT populations; with greater reduction in HbA1c and greater increase in weight observed in the RCT population than in the real-world population. Also, the basal-bolus regimens in both real-world and RCT populations showed greater reduction in HbA1c compared to the premix regimen (though more marked in RCTs), while the premix regimen showed greater increase in weight in real-world, as against basal-bolus in the RCT population.
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