To identify strategies that faciliate the implementation adaptation of peer support services to ensure continuity and effectiveness of mental health care during crisis or rapid organizational changes. This is a cross-sectional, qualitative study that was conducted during the COVID-19 pandemic with a purposeful sample of Veterans Health Administration (VHA) peer specialists and their supervisors from 11 facilities in a Veteran Integrated Service Network (VISN). Data collection and analysis were guided by the Consolidated Framework for Implementation Research (CFIR). Deductive and inductive thematic analysis approaches were used to analyze the data. VHA peer specialists employed various strategies that incorporated multiple CFIR domains to adapt to the COVID-19 restrictions and rapid organizational changes. Findings indicate that peer specialists as key individuals involved in delivering and implementing peer support services, as well as higher-level, outer setting factors such as patients' needs drove these adaptations. Some strategies and CFIR domains were more influential than others in shaping these adaptations. Three key strategies emerged as potentially useful in future public health crises and rapid organizational changes to expand the capacity of peer specialists' role to meet patients' healthcare needs: 1) adopting a work culture that is receptive to change (learning climate), 2) promoting collaboration (network and collaboration), and 3) fostering peer specialists' self-efficacy (characteristics of the individual). During times of crisis, foundational organizational practices, such as change management techniques and transformational leadership styles, can help support service delivery adaptations and improve care delivery to patients.
Early Support Hubs are an emerging model of youth mental health provision, designed to offer holistic, open-access support for young people whose needs often fall below the threshold for specialist services. Despite increased expansion in many countries, little is known about how these Hubs are implemented in practice or the challenges faced by those responsible for delivering them. This paper presents a qualitative interview study with 19 managers of Early Support Hubs in England. A codebook thematic analysis was used to explore managers' perceptions of the purpose of Early Support Hubs and factors that support or hinder effective implementation. Three overarching themes were identified. First, Hubs adopted a youth-centred, holistic ethos, characterised by open access and flexible support. Second, Hubs are balancing offers of early, brief interventions against the need for tailored/specialist support for some young people. Third, systemic factors key to effective delivery, include the need for strong inter-agency partnerships, a diverse and adaptable workforce, and sustainable funding. Early Support Hubs hold promise as an accessible, youth-led model that can plug gaps in traditional mental health systems and offer continuity across the transition into adulthood. However, these models are constrained by short-term funding cycles, workforce limitations, and rising demand from young people with more complex mental health needs. Establishing consistent service models, strengthening referral pathways, and securing long-term investment will be essential to realising the full potential of Early Support Hubs.
Healthcare professionals often report strong intentions to use evidence-based practices to improve patient care, but intention does not always translate into action. Habits, automatic behaviors generated through repeated cue-behavior associations, may help address the intention-behavior gap and enhance adoption of evidence-based practices. As habits form, behavior control shifts from being internally guided to being triggered by external context cues, which can support making the use of evidence-based practice more routine. Despite calls to integrate habit formation in implementation science, habits have not yet been fully leveraged to select and specify implementation strategies. We argue that habits can be explicitly planned for with targeted cues, behavior routines, and rewards to support healthcare professionals in adopting evidence-based practices. We outline core elements of habit formation and provide case examples to illustrate how habit techniques can be used to catalyze implementation in healthcare.
Despite policy efforts to expand integrated behavioral health care in the United States, substantial gaps remain in service delivery for people with co-occurring mental health (MH) and substance use disorders (SUD). Certified Community Behavioral Health Clinics (CCBHCs) are intended to close these gaps through enhanced financing and certification standards that mandate comprehensive, integrated MH–SUD services. Using the 2023 National Survey of Substance Use and Mental Health Services (N-SUMHSS) data for 1,480 facilities (198 CCBHCs, 448 community mental health centers [CMHCs], and 834 other outpatient MH facilities), this study compared service availability across three domains: engagement services, outpatient SUD treatment, and recovery support. Descriptive statistics characterized service provision, and multivariable logistic regressions estimated adjusted odds of service availability by facility type, controlling for ownership, government funding, and being a part of a multisite organization. Relative to other outpatient MH facilities, CCBHCs had significantly higher odds of providing engagement services, including interim services, outreach, and transportation, as well as outpatient SUD services, including outpatient detoxification and medication-assisted treatment. CCBHCs also exhibited greater availability of recovery-oriented support, including employment counseling, assistance obtaining social services, and housing supports. These findings provide some of the first national evidence that the CCBHC model is associated with substantially broader SUD-related service offerings than traditional CMHCs and other outpatient MH settings. By expanding both clinical SUD care and enabling services that reduce access barriers and address social determinants, CCBHCs appear well positioned to improve care continuity and recovery for individuals with co-occurring MH and SUD conditions.
Civilian-led crisis response teams provide emergency mental healthcare for individuals in acute distress in community settings, often without the involvement of police as first responders. These models represent one of several emerging alternatives to police-led crisis response and have gained attention for their potential to improve safety, trust, and care outcomes. Reports included in this scoping review discussed: the development, need, potential, implementation, and outcomes of civilian-led crisis response models. Covidence software was utilized by two independent reviewers to search 11 databases, with a third reviewer resolving conflicts. A dataset of 46 reports were then analyzed with thematic content analysis by a multidisciplinary team using critical theories to offer an exploration of how civilian-led crisis teams have begun to address the harms of policing responses to mental health. In exploring the key processes for civilian-led crisis response teams, three themes emerged. The first theme, Decentering Police, explores the growing collective awareness of the harms associated with police-involved crisis intervention and the corresponding need for alternative approaches, alongside efforts to establish a team composition that is intentionally distinct. The second theme, Team Scope of Practice, explores the subthemes of dispatch logistics and defining criteria for response. Team Sustainability is the third theme and explores how social and political will shape the uptake and long-term operation of civilian-led crisis programs.
Recovery-oriented mental health practice represents a paradigm shift toward holistic, client-centered care prioritizing autonomy, hope, and social integration for individuals with serious mental illness. Mental health practitioners are instrumental in facilitating recovery; however, mechanisms through which practitioner orientations translate into recovery-promoting competencies remain underexamined. Individuals with serious mental illness face disparities arising from stigma and structural inequities. Cultural humility, characterized by ongoing self-reflection, power awareness, and commitment to equitable partnership, has emerged as a critical orientation to operationalize recovery values. Yet mechanisms linking cultural humility to recovery-promoting competencies remain unclear. This study examines whether recovery attitudes mediate the relationship between cultural humility and recovery-promoting competencies among mental health practitioners. Data were collected via anonymous survey from 188 mental health practitioners (June 2024–March 2025) employed in U.S. mental health organizations providing clinical services to adults with serious mental illness. Structural equation modeling tested a mediation model using three latent variables: cultural humility, recovery attitudes, and recovery-promoting competencies. Results showed cultural humility was significantly associated with recovery attitudes (β = 0.638, p < .001), which in turn was associated with recovery-promoting competencies (β = 0.654, p < .001). Recovery attitudes mediated 54.9
Despite efforts to characterize the psychotherapeutic strategies used in routine children’s mental health services and develop pragmatic assessments of evidence-based practice (EBP) strategy delivery, research on the associations between EBP strategies and child outcomes is very limited. The Evidence-based Concordant Care Assessment (ECCA; Brookman-Frazee et al., 2021) is a measure designed to assess therapist delivery of evidence-based strategies in children’s mental health services. Previous research on the predictive validity of the ECCA indicates that a subset of ECCA Technique strategies are associated with child mental health outcome trajectories across presenting problems. The current study extends analyses to identify ECCA Content strategies associated with caregiver-reported outcome trajectories for children with specific presenting problems, and for distinct age groups. Data were obtained from 1,380 sessions with 248 children being served by 76 therapists in two county systems. Child primary presenting problems included: depression (32
Mental health problems among children and adolescents are common worldwide and pose substantial challenges for health and welfare services. There is an increasing need for effective interventions to prevent and reduce child mental health problems in Norwegian municipal child and family services. Few such interventions have been implemented and made available for the target group. Supportive Parents - Coping Kids is a novel, transdiagnostic parent-based intervention targeting both internalizing and externalizing symptoms in children. The intervention has been co-created, tested, and refined with relevant stakeholders to promote its acceptability, appropriateness, and feasibility in regular municipal services. Insufficient understanding and consideration of contextual factors, particularly in complex psychosocial interventions like the present one, may contribute to the persistent gap between research and practice. Guided by the Consolidated Framework for Implementation Research, this qualitative study explores facilitators and barriers to successful implementation of the intervention. Facilitators, barriers, and latent themes were identified through a combination of inductive content analysis and thematic analysis of semi-structured interviews with 29 practitioners and leaders across seven municipalities. In the study we identify four key themes: (1) meeting the need, (2) confidence in the intervention, (3) balancing flexibility with complexity, and (4) navigating resource constraints. From a critical realist perspective, these themes were interpreted to suggest mechanisms that either promote or hinder successful implementation of this and comparable complex interventions.
This study presents suicide surveillance findings from the Veterans Health Administration (VHA) Suicide Risk Encyclopedia, a novel population-based suicide rate comparison tool, demonstrating which Veteran VHA patient subpopulations experience the most elevated suicide rates. For cohorts of Veteran VHA patients alive as of the last day of 2016, 2017, 2018, 2019, and 2020 and with VHA encounters in the prior 2 years, we assessed subpopulation size, number of suicide deaths in the subsequent calendar year, and the suicide rate for 482 measures of Veteran characteristics, diagnoses, and services utilization. We compared suicide rates across measures and years and rank-ordered subgroups by suicide rates. For subgroups with at least 20 suicides from 2017 to 2021, the measures with the highest suicide rates were: prior-year suicide attempts (suicide rate: 380.9/100,000 person-years), high-risk Veterans Crisis Line (VCL) calls (i.e., calls rated as high risk by the VCL responder; 354.1/100,000 person-years), moderate-to-high-risk VCL calls (276.6/100,000 person-years), VHA suicide high risk flag receipt (263.8/100,000 person-years), and suicidal ideation diagnostic codes (257.5/100,000 person-years). For measures with a prevalence of at least 10%, the measures with the top suicide rates were alcohol use disorder diagnoses (99.8/100,000 person-years), anxiolytic prescriptions (87.9/100,000 person-years), non-psychotherapy and medication management mental health outpatient encounters (e.g., 82.7/100,000 person-years), unspecified anxiety disorder diagnoses (75.0/100,000 person-years), and other-specified depression diagnoses (73.5/100,000 person-years). Findings identify high risk VHA patient subpopulations, provide information on trends, and include data regarding subpopulation sizes. These findings highlight the potential value of health systems developing population-based risk comparison tools.
Peer work and Lived Expertise are vital for shaping individual and collective understandings of mental health, addiction, and behavioral health service systems. Culturally and Racially Marginalized [CARM] people are underrepresented in peer support work but also encounter multiple challenges as they navigate often traditional service settings. There is an urgent need for more diverse voices within these spaces, especially those of CARM communities. This research aims to contribute to a deeper understanding of the complexities surrounding experiences of equity, diversity, inclusion, and belonging by peer workers employed in traditional behavioral health settings. Employing grounded theory methods to guide data collection and analysis, it examined qualitative data derived from a larger study of peer workers from five multidisciplinary organizations in the United States. The analysis identified key themes and challenges encountered by diverse CARM peer workers within behavioral health systems. The themes include: Potential enablers for CARM individuals in peer work contexts; Mental health and AOD systems dominated by white cultural perspectives; CARM people not having a voice in the peer movement; and Challenges faced by CARM people within peer work contexts and when taking on peer work roles. Each domain was divided into subthemes that either support or hinder the promotion of cultural responsiveness in settings that center lived experience and Lived Expertise. The findings of this study have significant implications for practice, underscoring the need for systemic and structural changes to ensure peer work environments are inclusive, equitable, and reflective of the diverse, intersectional communities they serve.
In 2017, the U.S. Centers for Medicare and Medicaid Services approved reimbursement for billing codes specific to the Collaborative Care Model (CoCM), an evidence-based practice for improving access and quality of behavioral health services in primary care. However, it remains unclear how reimbursement through these billing codes aligns with applications of CoCM for complex patient populations, such as those with co-occurring mental and substance use disorders. We examined the reimbursement potential of CoCM intervention activities documented during a pragmatic clinical trial of CoCM for patients with opioid use disorder co-occurring with depression and/or post-traumatic stress disorder. We defined reimbursement potential based on federal (i.e., Medicare) CoCM billing code rules and reimbursement rates, as of 2024. Across 381 patients and 10 care managers (i.e., the CoCM interventionists), we documented 90,996 total intervention activity minutes in the project’s care management registry. Under ideal conditions where all CoCM billing codes can be and are used, a maximum of 56
Non-suicidal self-injury (NSSI) is common in inpatient mental health care and poses challenges for staff, patients, and organizations. While training programs can improve knowledge and attitudes, less is known about how staff collectively experience implementing new strategies for managing self-harm and how such strategies influence ward culture and professional practice. This qualitative study was part of a broader evaluation of implementing a regional self-harm strategy in a Danish inpatient mental health service. The strategy included staff training, clinical tools, and supervision. Four focus group interviews with 25 staff members from five inpatient units were conducted in 2024. Data were analyzed using reflexive thematic analysis. The analysis generated four interrelated themes: (1) Relational work as invisible yet essential: Staff valued listening and dialogue as crucial for preventing escalation but described these practices as undervalued and the first to be dropped under pressure. (2) Diagnostic hierarchies: psychosis as the legitimate inpatient diagnosis, self-harm as responsibility: Psychotic patients were viewed as genuinely ill and beyond control, while patients who self-harm were often framed as responsible, sustaining moralized hierarchies of care. (3) Cultural change – from control to dialogue: The strategy disrupted routines of restraint in relation to self-harm. Initially perceived as “doing nothing,” the new strategy was increasingly legitimized as staff witnessed calmer units, reduced coercion, and clearer professional roles grounded in relational practice. (4) Responsibility, guilt, and emotional distance — Staff struggled with the emotional and moral burden of refraining from coercion, negotiating professional boundaries, and managing feelings of guilt and emotional withdrawal. Implementing a self-harm strategy requires more than new clinical tools. It depends on staff integrating the approach into everyday practice, supported by structural and cultural change. Sustainable implementation relies on legitimizing relational care as skilled clinical work, creating space for reflection, and addressing the emotional demands placed on staff. The findings also show that diagnostic hierarchies continue to shape how legitimacy and responsibility are distributed within psychiatric care.
In 2013, premenstrual dysphoric disorder (PMDD) was officially recognized as a psychiatric diagnosis. It is estimated to affect 1.3
Less than half of insured Americans can access mental health care due to a variety of barriers, including low provider participation in insurance networks. Providers report insufficient reimbursement rates and administrative burdens as reasons they do not accept insurance. We examined the importance of these barriers and the extent to which reimbursement rates would need to increase for private practice providers to accept insurance. Private practice mental health providers (i.e., psychologists, marriage and family therapists, mental health counselors, and social workers) completed an online survey containing two behavioral economic tasks. In the Criteria Ranking Task, providers (n = 326) ranked barriers that most deterred them from accepting insurance, reporting insufficient reimbursement rates as the most important, followed by administrative burdens. In the Hypothetical Demand Task, providers indicated the likelihood of accepting Medicare at various reimbursement rate increases with and without hypothetical administrative assistance. Participants indicated they would accept insurance following 83
Examples of system-driven implementation of multiple evidence-based practices (EBPs) are becoming more frequent in efforts to improve community mental health care, but there is limited understanding of how these efforts change community therapist practice. Within one such implementation effort in the Los Angeles County Department of Mental Health, this observational study sought to: (1) examine observer ratings of therapist delivery of EBP strategies in sessions where therapists claimed reimbursement to one of six youth mental health EBPs; and (2) explore factors associated with extensiveness of EBP strategy delivery. Data were drawn from 680 sessions with 273 youth delivered by 103 therapists in 14 agencies. Sessions were audio recorded and rated by trained observers for extensiveness of therapist delivery of EBP technique and content strategies. Therapists were observed to use EBP techniques (Structuring Treatment Techniques and Skill Building Techniques) in the majority of sessions. Consistent with expectations, use of specific EBP content strategies were more targeted and less commonly observed at every session. Finally, the following factors were associated with higher observed EBP strategy extensiveness: sessions completed in a non-English language (compared with sessions completed in English), sessions using an EBP with a prescribed session content/order (compared with sessions using an EBP without a prescribed session content/order), higher levels of therapist reported self-efficacy with the EBP being delivered, older client age, and therapists with a cognitive behavioral theoretical orientation (compared with therapists with an orientation other than cognitive behavioral). Patterns of therapist EBP strategy delivery followed expected patterns, with techniques strategies used in the majority of sessions and specific content strategies used in a more targeted fashion. Given the dearth of observational measurement of EBP implementation-as-usual, these findings contribute to our understanding of key outcomes of scale-up efforts. Predictors of EBP strategy use have implications for targeting efforts to promote sustainment, such as improving provider EBP self-efficacy.
The practice of using validated rating scales to guide treatment—measurement-based care (MBC) remains underutilized in behavioral health. This study examined the association between real-world MBC implementation, ascertained by measure completion, and emergency department (ED) visits. A retrospective cohort design made use of medical insurance claims data (2015–2023) to examine adult psychiatric outpatients exposed to real-world MBC (“MBC” sample; n = 524); 482 were propensity score-matched to patients who received care as usual (“CAU” sample; n = 964). The index visit was the date of registry enrollment for the MBC sample and the first psychiatric encounter while enrolled for the CAU sample. Time-to-event and negative binomial models were used to estimate hazard ratios (HRs) and incidence rate ratios (IRRs) for ED visits. The overall sample included 1,488 patients (63
Stigma remains a critical social determinant of health for individuals with serious mental illnesses (SMIs), influencing access to resources, social inclusion, and overall well-being. This study uses a multi-method approach to examine how individual and interpersonal stigma operate within social networks, shaping experiences of exclusion, disclosure, safety, and community participation. Using semi-structured qualitative interviews and egocentric social network interviews, we employed case study and thematic analysis to examine sources and types of stigma among 30 participants with SMIs receiving community-based services in a large Western U.S. city. Findings highlight three primary stigma types—anticipated, experienced, and internalized—emerging within social networks, with family members, friends, service providers, and acquaintances identified as sources of stigma. The interplay between stigma types within social networks contributed to downstream psychological and behavioral consequences, including self-imposed isolation, disclosure dilemmas, and heightened safety concerns. These findings underscore the need for multi-level interventions that address stigma at both the individual and interpersonal levels, including challenging negative self-perceptions, strengthening social support networks, and fostering inclusive environments. By examining stigma in social networks, this study contributes to a growing body of qualitative research on stigma, mental health, and community participation, offering critical insights for policy, practice, and future research.
The built environment of Emergency Departments (EDs) provides the context and setting for care delivery, influences workflows, and shapes user interactions, but its noisy, sterile, stimulating nature can be counter-therapeutic to patients in psychiatric crises. As ED Mental and Behavioral Health (MBH) presentation rates rise, healthcare organizations and designers must develop strategies to address challenges and improve care. This systematic review analyzes emergency department-based built environment interventions implemented to improve the safety and experiences of patients seeking emergency MBH care and ED staff involved in their care. Our team searched six databases in March 2023 using PRISMA methods and the SEIPS 3.0 framework to identify and analyze nineteen studies of ED-based built environment interventions for MBH care. Interventions occurred at three scales - unit, room, and element - and impacted patient and staff outcomes. For example, MBH units located outside of the main ED contributed to decreases in length of stay, boarding, and inpatient psychiatric admissions. Room and element-scale interventions helped improve patient experiences and increase safety. This review summarizes existing knowledge surrounding built environment interventions for emergency MBH care and identifies opportunities for design and clinical practice applications. Future research is necessary to capture patient and staff voices, examine various types of EDs, and compare interventions across hospitals. This review shows how physical interventions in the built environment of EDs - from individual elements to entire units - can improve processes, safety, and experiences for MBH patients and staff, especially when incorporated into broader, systems-based changes.
Recent decades have seen emergence of numerous evidence-based early parenting interventions. To make an impact at a population level, they need to be delivered at scale. This study aimed to identify factors that enable successful scaling of early parenting interventions for sustainable implementation and impact. Participants were 22 individuals from the United States of America, Australia, Korea and the Netherlands, all who had experience in the development, implementation dissemination and/or scaling of early parenting interventions. Participants completed in-depth interviews about their experiences or observations of scaling early parenting intervention, and enablers and barriers to successful scaling. Transcripts were analysed using thematic analysis. Results revealed six key themes: (1) adopting a business mindset, including sustainable funding and governance models; (2) securing multi-level stakeholder buy-in, from clinicians to policymakers; (3) implementing flexible, context-sensitive models that support fidelity and adaptation; (4) ensuring intervention quality, including evidence-based design and cultural relevance; (5) assembling multidisciplinary teams with the necessary expertise and leadership; and (6) time and planning. Results suggest that scaling early parenting interventions is a dynamic, non-linear process that can take considerable time and planning. Scaled interventions need to be evidence-based and culturally relevant, but there also needs be a sound business model, widespread stakeholder involvement, and strong leadership. Sensitivity and flexibility to meet the needs of local contexts are also vital. Taken together, this study offers actionable insights for policymakers, funders, and practitioners seeking to expand the reach and impact of early parenting interventions within diverse service systems.
Depression is a leading cause of global disease burden. Although psychotherapy and pharmacotherapy effectively reduce depressive symptoms, access to high-quality care remains limited. This study examined whether a Continuous Quality Improvement (CQI) process incorporating measurement-based care and benchmarking could enhance depression treatment outcomes in specialized mental healthcare. Data were drawn from two outpatient mental health clinics in Stockholm, Sweden. First, patient-reported outcome measures (PROMs) were used to compare local clinical results with a meta-analytic benchmark. Next, a CQI framework was implemented to improve outcomes. The sample included 415 patients receiving treatment for depression. Compared to the benchmark, the clinical sample had higher pre-treatment depression severity, attended more appointments, and had lower data attrition. Initial year-to-year analyses showed that treatment effects were significantly lower than the benchmark (Hedge’s g = 0.87–1.01 vs. g = 1.51). After implementing the CQI process, treatment effects improved (g = 1.25–1.27) and were no longer inferior to the benchmark. These findings suggest that integrating measurement-based care, benchmarking, and CQI can improve depression treatment outcomes in specialized settings and may help close the gap between real-world care and evidence-based standards.
