Cognitive-behavioral therapy (CBT) is a first-line intervention for anxiety and mood disorders, yet its reach has not been fully realized due to incomplete implementation in routine community practice. The field of implementation science has the potential to improve integration of CBT in the settings and populations that most stand to benefit. Numerous strategies have been proposed to improve implementation, but are not consistently specified in the research, particularly in CBT research and practice. The present narrative review is intended to demonstrate to mental health clinicians, researchers, and policy-makers the ways in which implementation strategies can be utilized and specified to improve implementation of CBT, using a previously developed implementation strategy classification scheme as a guide. We describe the categories of strategies, provide exemplars of their use in CBT research and implementation efforts, and summarize the implications of each category type for CBT practice and research. We conclude with a hypothetical implementation study illustrating optimal use and specification of these strategies targeting implementation of CBT for OCD.

A significant portion of mothers (pregnant and postpartum) enrolled in U.S. home visiting programs report clinically significant depressive symptoms. Non-violent family conflict precipitates and exacerbates their depressive symptoms. This pilot randomized trial tested the preliminary effectiveness of a family therapy intervention, Resilience Enhancement Skills Training (REST), compared to the standard of care in home-visited mothers with moderate to severe depressive symptoms and moderate to high conflict with family members. A total of 83 mothers and their family members (N = 166) were randomized to receive REST or the standard of care. Both interventions were delivered by clinicians using HIPAA-compliant video conferencing technology. Outcomes were assessed by research assistants, blinded to study group assignment, at post-intervention, 3, and 6 months later. Linear mixed-effects models were used to analyze changes in continuous outcomes in mothers and family members, separately. Mixed-effects logistic regression was used to analyze changes in maternal job attainment/school enrollment. Participants in both study groups showed improvements in outcomes. When compared to standard-of-care participants, REST participants had significantly greater reductions in family conflict (mothers ES = -1.19, family members ES = -0.77), maternal depressive symptoms (ES = -0.96) and co-occurring anxiety symptoms (ES = -0.59), and greater increases in family cohesion (mothers ES = 0.99, family members ES = 0.94) and maternal job attainment/school enrollment (ES = 0.70). The results highlight the value of family therapy for the treatment of moderate to severe depressive symptoms in home-visited mothers, including those with co-occurring moderate to severe anxiety symptoms. Trial Registration: Registered in ClinicalTrials.gov on 02/04/2021. NCT04741776 https://clinicaltrials.gov/ct2/show/NCT04741776.

Background:Certified peer support specialists (CPSs) can empower individuals with serious mental illness (SMI) to engage with mobile health interventions designed to improve medical and psychiatric self-management. This study pilot-tested PeerTECH, a digital, 12-session intervention adapted from Integrated Illness Management and Recovery and delivered by CPSs, to assess its feasibility, acceptability, and preliminary effectiveness in enhancing self-management among individuals with SMI compared to peer support as usual (PSAU). Methods:A two-arm pilot randomized controlled trial was conducted with individuals diagnosed with SMI and at least one medical comorbidity. Participants were randomly assigned to either PeerTECH, a 12-week structured mobile health intervention delivered by CPSs, or PSAU (peer support without mobile technology). Outcome measures related to medical and psychiatric self-management were assessed at baseline and 12 weeks. Data was analysed using linear mixed-effects regression models to compare outcomes between groups. Feasibility and acceptability were evaluated by participant retention rates, intervention adherence, and participant-reported satisfaction. Results:The study demonstrated that the randomized control trial design was feasible and acceptable, with 72.73% of approached patients consenting to participate. PeerTECH delivery was engaging, with 90% of participants initiating the intervention, approximately 80% completing it, and participants engaging in text exchanges on 70% of possible days, averaging 10 text exchanges. The intervention was found to be acceptable, with 100% of participants reporting satisfaction, and safe, with no adverse events. Statistically significant improvements were observed in PeerTECH compared to PSAU in physical health outcomes, as measured by the Patient-Reported Outcomes Measurement Information System (PROMIS) Global-10 Physical Health scores (P=0.023). Clinically meaningful improvements in the Integrated Management and Recovery Scale and PROMIS-derived utility scores (EuroQol 5-Dimension Scale, Health Utilities Index) were also observed. Conclusions:The Peer-Led Mobile Health Intervention demonstrated feasibility and effectiveness in enhancing self-management among individuals with SMI and chronic comorbidities. Trial Registration:This trial was registered at ClinicalTrials.gov (NCT04481737).

BACKGROUND:Leaders in the field have called for exercise counseling to become standard of care by 2029. An Affect-based exercise prescription (Affect-Rx) may be a viable strategy for supporting this effort. AIMS:Guided by the ORBIT Model for developing behavioral treatments, this Phase 1b study evaluated breast cancer survivors' perceived acceptability of Affect-Rx. Additionally, the feasibility of trial methods and opportunities for protocol refinements were assessed. METHOD:Participants were 36 stage 0-III breast cancer survivors within 5 years of completing primary cancer treatment. Demographics were collected at baseline and via medical record review. Affect-Rx was delivered in conjunction with a low-touch, physical activity promotion intervention over videoconference call. At end-of-study, participants rated Affect-Rx using the Treatment Acceptability and Preferences (TAP) Measure. Participants responded to the Stanford L-Cat at baseline and end-of-study. ActiGraph wGT3X-BT accelerometers measured moderate-vigorous physical activity (MVPA) over 10-day periods at baseline and follow-up. RESULTS:Affect-Rx was rated acceptable (TAP overall M = 3.30, SD = 0.53). Study retention and accelerometer measurement completion was ≥ 80% across time. L-Cat scores were discordant from accelerometer-measured MVPA at baseline. CONCLUSIONS:Affect-Rx warrants further testing. The trial methods were feasible; however, physical inactivity verification procedures along with targeted recruitment efforts are needed to support future work. The field needs intervention strategies that can be deployed with limited resources and at low cost to offer survivors exercise counseling support in line with the new National Standards for Cancer Survivorship Care, the affect-based exercise prescription is designed to serve this mission. TRIAL REGISTRATION:The study protocol was registered with ClinicalTrials.gov prior to the initiation of participant recruitment NCT04903249.

OBJECTIVES:Direct admission (DA) to the hospital has the potential to improve family satisfaction and timeliness of care by bypassing the emergency department. Using the RE-AIM implementation framework, we sought to characterize variation across health systems in the reach, effectiveness, adoption, and implementation of a DA program from the perspectives of parents and multidisciplinary clinicians.METHODS:As part of a stepped-wedge cluster randomized trial to compare the effectiveness of DA to admission through the emergency department, we evaluated DA rates across 69 clinics and 3 health systems and conducted semi-structured interviews with parents and clinicians. We used thematic analysis to identify themes related to the reach, effectiveness, adoption, and implementation of the DA program and applied axial coding to characterize thematic differences across sites.RESULTS:Of 2599 hospitalizations, 171 (6.6%) occurred via DA, with DA rates varying 10-fold across health systems from 0.9% to 9.3%. Through the analysis of 137 interviews, including 84 with clinicians and 53 with parents, we identified similarities across health systems in themes related to perceived program effectiveness and patient and family engagement. Thematic differences across sites in the domains of program implementation and clinician adoption included variation in transfer center efficiency, trust between referring and accepting clinicians, and the culture of change within the health system.CONCLUSIONS:The DA program was adopted variably, highlighting unique challenges and opportunities for implementation in different hospital systems. These findings can inform future quality improvement efforts to improve transitions to the hospital.

OBJECTIVE:Direct admission (DA) to hospital can reduce emergency department (ED) utilization by bypassing the ED during the admission process. We implemented a DA program across 3 health systems and compared timeliness of care, family experience of care, and post-admission clinical deterioration among children admitted via DA versus the ED after their clinic was randomized to begin the DA program. METHODS:Using a stepped-wedge design, 69 primary and urgent care clinics were randomized to 1 of 4 time points to begin a voluntary DA program, February 1, 2020 to April 30, 2023. Outcomes in children <18 years admitted with 7 common medical diagnoses were compared using adjusted logistic or linear regression. RESULTS:A total of 2599 children were admitted with eligible diagnoses during the study period , including 145 children admitted directly and 1852 admitted through EDs after program implementation at their clinic. Median age was 2.8 (interquartile range: 1.1-6.8) years, 994 (49.8%) were female, and 1324 (66.3%) were Medicaid-insured. Adjusted regression analyses showed that if each child was admitted via DA versus the ED, average time to initial clinical assessment was 3.1 minute (95% confidence interval: 1.7-4.5) slower, whereas time to initial therapeutic management was 49.6 minutes faster on average (95% confidence interval: 30.3.2-68.9). There were no significant differences in time to initial diagnostic testing or rates of post-admission clinical deterioration. CONCLUSIONS:Compared with ED admission, DA appears equally safe and acceptable to families, and may be associated with a significantly shorter time to initial therapeutic management with modestly longer time to initial clinical assessment.

OBJECTIVE:The objective of this trial was to determine the feasibility, acceptability, and preliminary effectiveness of sharing audio recordings of primary care visits with older adults with multimorbidity. METHODS:We used a two-arm, randomized, controlled, feasibility trial with 3-month follow-up. Patients aged ≥ 65 years-with diabetes and hypertension-were recruited from academic primary care settings in New Hampshire, Tennessee, and Texas. Patients were randomized to receive online access to audio recordings of scheduled visits for three-months or care as usual (after visit summaries). Primary outcomes were acceptability and feasibility assessed using several indicators: acceptabilityrecruitment of 90 patients; recording use; and the Appropriateness of Intervention Measure (AIM; >3), feasibility- retention rate; protocol adherence; and the Feasibility of Intervention Measure (FIM; >3). Interviews were conducted with clinicians (n = 14) and patients (n = 19). Exploratory outcomes included patient activation, satisfaction, adherence, and quality of life. RESULTS:We met recruitment (n = 91) and retention (98 %) targets and exceeded feasibility (Median FIM 4; IQR 3 - 4) and acceptability (Median AIM 4; IQR 3 - 4) metrics. Fidelity to protocol was high (92 %), and 40 of 45 patients (85 %) accessed their recordings. Interviewees noted the benefits of visit recording, including greater recall, understanding, and family engagement. Recording had little perceived impact on the visit interaction, and concerns about visit recording were minimal. Exploratory outcomes revealed better PROMIS Mental Health Scores for patients receiving Audio compared to Usual Care at 3 months: 51.5 (SD 7.7) vs. 47.7 (SD 9.9), P = 0.04. CONCLUSIONS:Sharing visit recordings online with older adults is feasible and acceptable. A larger trial is needed to determine the impact of sharing recordings on patient health outcomes. PRACTICE IMPLICATIONS:Recording is a highly scalable approach to supporting older adults and their care partners in managing care. Advances in natural language processing may unlock further opportunities for this innovative strategy.

The Advanced Research Institute (ARI) in Mental Health and Aging is a NIMH-funded mentoring network to help transition early-career faculty to indepen-dent investigators and scientific leaders. Since 2004, ARI has enrolled 184 Schol-ars from 61 institutions across 34 states. We describe the ARI components and assess the impact and outcomes of ARI on research careers of participants. Out-comes of ARI graduates (n = 165) came from NIH Reporter, brief surveys, and CVs: 87.3% remained active researchers, 83.6% performed scientific service, and 80.6% obtained federal grants. A population-based analysis examined NIMH mentored K awardees initially funded from 2002-2018 (n = 1160): in this group, 77.1% (47/61) of ARI participants versus 49.5% (544/1099) of non-participants obtained an R01. Controlling for time, ARI participants were 3.2 times more likely to achieve R01 funding than nonparticipants. Given the struggle to reduce attrition from the research career pipeline, the effectiveness of ARI model could be relevant to other fields. (Am J Geriatr Psychiatry 2023; 31:1209-1215)

Godzik, Cassandra M. PhD, APRN; Bruce, Martha L. PhD, MPH; Lyons, Kathleen D. ScD, OTR/L Author Information

BackgroundAlthough individual-level treatments exist for pregnant and postpartum women with depression, family conflict is a significant factor that can contribute to the development and severity of perinatal depressive symptoms. Yet, there is a lack of research on family therapy for perinatal women with moderate to severe depressive symptoms and family conflict. Further, research is needed on the feasibility, acceptability, safety, and tolerability of family therapies for perinatal depression that are delivered using Health Insurance Portability and Accountability Act–compliant videoconferencing technology (VCT). ObjectiveThis paper describes the feasibility, acceptability, safety, and tolerability of a VCT-based family therapeutic intervention, Resilience Enhancement Skills Training (REST), for perinatal women with moderate to severe depressive symptoms and moderate to high conflict with their family members. MethodsThis paper includes data from an ongoing randomized trial that compares an experimental family therapeutic intervention (REST) to standard of care (VCT-based problem-solving individual therapy) for the treatment of moderate to severe depressive symptoms in perinatal women with moderate to high family conflict. Both interventions were delivered by masters-level therapists using VCT. A total of 83 perinatal women and their adult family members (N=166 individuals) were recruited for participation in the study. Feasibility, defined as therapist adherence to ≥80% of REST session content, was assessed in audio-recorded sessions by 2 expert raters. Acceptability was defined as ≥80% of families completing REST, including completion of ≥80% homework assignments and family report of satisfaction with REST. Completion of REST was assessed by review of therapist session notes, and satisfaction was assessed by participant completion of a web-based questionnaire. The Beck Depression Inventory-Second Edition was administered to perinatal women by research assistants (blind to study group assignment) to assess safety, defined as a reduction in depressive symptoms during the treatment phase. The Family Environment Scale-Family Conflict subscale was administered by therapists to participants during the treatment phase to assess tolerability, defined as a reduction in family conflict during the treatment phase. ResultsOn average, the therapists achieved 90% adherence to REST session content. Of the families who started REST, 84% (32/38) of them completed REST, and on average, they completed 89% (8/9) of the homework assignments. Families reported satisfaction with REST. The results showed that REST is safe for perinatal women with moderate to severe depressive symptoms, and none discontinued due to worsened depressive symptoms. The results showed that REST is well tolerated by families, and no families discontinued due to sustained family conflict. ConclusionsThe results show that REST is feasible, acceptable, safe, and tolerable for families. These findings will guide our interpretation of REST’s preliminary effectiveness upon completion of outcome data collection. Trial RegistrationClinicalTrials.gov NCT04741776; https://clinicaltrials.gov/ct2/show/NCT04741776

Socioeconomically disadvantaged women experience barriers to attending postpartum medical visits (PMV). This three-phase pilot study explored the feasibility, acceptability, and preliminary effectiveness of an educational intervention to increase PMV attendance in mothers enrolled in early childhood home visiting. Phases 1 and 2 occurred prior to the COVID-19 pandemic, and Phase 3 occurred during the pandemic. Home visitor implementation of the intervention with mothers was feasible and acceptable in all phases. All mothers who received the intervention reported PMV attendance. Overall, 81% of mothers reported they discussed all questions with healthcare providers at the PMV. These findings provide preliminary effectiveness for a brief educational intervention in increasing PMV attendance in home-visited mothers.

Senior centers and aging service providers provide national infrastructure for delivering mental health services to older adults in need. Given that older adults involved in senior centers, dining sites, and other aging services exhibit high mental health needs, this infrastructure shows great promise for preventing and ameliorating depression, anxiety, loneliness, and other mental health issues. This session describes three programs and evaluation results of behavioral health screening and interventions integrated into senior centers and aging service organizations, delivered by embedded mental health clinicians and older adult volunteers. The first presentation describes an ongoing three-site RCT of behavioral activation delivered by master's level clinicians or a streamlined behavioral activation intervention delivered by older adult volunteers for depressed senior center clients, describing the methods, interim training results, and preliminary feedback from clients and volunteers. The second presentation describes a large-scale dissemination initiative of mental health screening and services across 30 senior centers in New York City, involving 894 older adults screened and 4,749 intervention sessions delivered in one year by embedded mental health clinicians, with reductions in depressive and anxiety symptoms for many. The third presentation describes a pilot RCT with 40 depressed senior center clients, comparing a Stay Connected virtual intervention delivered during the COVID-19 pandemic to usual care, observing improvements in depressive symptoms for the Stay Connected intervention. The three programs illustrate the value of screening and evidence-based interventions delivered by embedded mental health clinicians, aging service personnel, and older adult volunteers. The discussant will review key findings and themes and facilitate discussion among the speakers and audience.

Digital recordings of clinic visits offer an opportunity to promote patient and family engagement in care. Using advances in natural language processing (NLP), we have developed HealthPAL (Personal Audio Library). HealthPAL is open-access software that highlights key information (e.g., medications) from visit recordings, and links to trustworthy web-based resources. The objective of this trial is to demonstrate the successful use of HealthPAL at home by older adults. We conducted a three-arm, parallel-group, patient-randomized, blocked, controlled, pilot trial at Dartmouth-Hitchcock. Patients were ?65 years with two or more chronic diseases. Patients visiting primary care were randomized to 1) usual care, 2) simple recording or 3) HealthPAL. We assessed recruitment feasibility and retention. Assessments were completed at baseline and 2 weeks from enrollment. System usability, feasibility, acceptability, and appropriateness of the recording interventions were assessed using validated metrics. While not powered, we also explored potential impact on patient activation, satisfaction, adherence, QOL, interpersonal communication, electronic health literacy, and caregiver preparedness. We enrolled 4 of 4 clinicians approached, exceeded patient enrollment milestones (n=45 of 45 patients), and achieved high retention (91%) and high fidelity to our trial protocol. Patients were 78 years old (SD 5.9) and 65% female. Feasibility, acceptability, and appropriateness of intervention were a median of 4 out of 5, and system usability score was 70.6 for HealthPAL, indicating above-average usability. As expected, no significant difference in outcomes was found, however, there was a non-significant increase in electronic health literacy in the HealthPAL group from baseline (+3.2). Visit recordings are a highly usable, feasible, and acceptable way of communicating visit information to older adults. The use of NLP to curate visit recordings is an innovative strategy to optimize visit communication and promote greater self-management. A powered trial is needed to determine the impact on patient outcomes.

Objective: To assess the feasibility, acceptability, and preliminary effectiveness of digital peer support integrated medical and psychiatric self-management intervention ("PeerTECH") for adults with a serious mental illness. Methods: Twenty-one adults with a chart diagnosis of a serious mental illness (i.e., schizophrenia, schizoaffective disorder, bipolar disorder, or treatment-refractory major depressive disorder) and at least one medical comorbidity (i.e., cardiovascular disease, obesity, diabetes, chronic obstructive pulmonary disease, hypertension, and/or high cholesterol) aged 18 years and older received the PeerTECH intervention in the community. Nine peer support specialists were trained to deliver PeerTECH. Data were collected at baseline and 12-weeks. Results: This pilot study demonstrated that a 12-week, digital peer support integrated medical and psychiatric self-management intervention for adults with serious mental illness was feasible and acceptable among peer support specialists and patients and was associated with statistically significant improvements in self-efficacy to manage chronic disease and personal empowerment. In addition, pre/post non-statistically significant improvements were observed in psychiatric self-management, medical self-management skills, and feelings of loneliness. Conclusions: This single-arm pre/post pilot study demonstrated preliminary evidence peer support specialists could offer a fidelity-adherent digital peer support self-management intervention to adults with serious mental illness. These findings build on the evidence that a digital peer support self-management intervention for adults with serious mental illness designed to improve medical and psychiatric self-management is feasible, acceptable, and shows promising evidence of improvements in clinical outcomes. The use of technology among peer support specialists may be a promising tool to facilitate the delivery of peer support and guided evidence-based self-management support. Conclusions: People with serious mental illness (SMI; defined as individuals diagnosed with schizophrenia spectrum disorder, bipolar disorder, or treatment-refractory major depressive disorder) are increasingly utilizing peer support services to support their health and recovery. Peer support is defined as shared knowledge, experience, emotional, social, and/or practical assistance to support others with similar lived experiences (Solomon, 2004). Most recently the definition also includes the provision of evidence-based peer-supported self-management services (Fortuna et al, 2020). Mental health peer support can augment the traditional mental health treatment system through providing support services to maintain recovery between clinical encounters (Solomon, 2004) and is classified by the World Health Organization as an essential element of recovery (World, Health, and Organization, About soda) determinants of health, 2017).

Pregnant women with criminal legal involvement and opioid use disorder (CL-OUD) living in non-urban regions may be at risk for complex biomedical, psychological, and social barriers to prenatal care and healthy pregnancy. Yet, limited research has explored prenatal care utilization patterns among this subpopulation. This study describes the biopsychosocial factors of pregnant women with a history of criminal legal involvement and opioid use disorder (CL-OUD) associated with timely prenatal care initiation and adequate prenatal care utilization (APNCU). Analyses were conducted on a subsample of medical record data from an observational comparative effectiveness study of medication treatment models for pregnant women with diagnosed opioid use disorder (OUD) who received prenatal care in Northern New England between 2015 and 2022. The subsample included women aged ≥ 16 years with documented criminal legal involvement. Analyses included χ2, Fisher exact tests, and multiple logistic regression to assess differences in timely prenatal care and APNCU associated with biopsychosocial factors selected by backwards stepwise regression. Among 317 women with CL-OUD, 203 (64.0

BACKGROUND AND PURPOSE:Among people with multiple sclerosis (MS), yoga has potential to improve fatigue and other symptoms that undermine quality of life. The aim of this study was to assess the feasibility, acceptability, and effectiveness of LoveYourBrain Yoga, a six-week yoga with psychoeducation program, on fatigue and other health-related outcomes among people with MS in a rural, community-based setting in the United States.METHODS:This non-randomized 2x2 crossover pilot trial compared LoveYourBrain Yoga to a control among 15 people with MS. People were eligible if they were adults with MS (EDSS score ≤6), English-speaking, and ambulatory. Paired t-tests and Wilcoxon signed rank sum analyses assessed mean differences in PROMIS-FatigueMS, Multiple Sclerosis Impact Scale, Symbol Digit Modalities Test, NIH Neuro-QoL measures, and Liverpool Self-Efficacy scale. We assessed feasibility using recruitment and retention rates, mean attendance, fidelity, and acceptability using satisfaction measures.RESULTS:Significant improvements in fatigue (MD -4.34, SD 5.26, p = 0.012), positive affect and wellbeing (MD 2.76, SD 3.99, p = 0.028), and anxiety (MD -4.42, SD 5.36, p = 0.012) were found after LoveYourBrain Yoga compared to the control. Participants reported high satisfaction (M 9.5, SD 1.4) and a majority (92.3%) reported 'Definitely, yes' to recommending it to a friend or family.CONCLUSION:LoveYourBrain Yoga is feasible and acceptable when implemented in a rural, community-based setting for people with MS. It may improve a range of MS symptoms and offer a means for acquiring new skills for stress reduction, anxiety management, and overall wellbeing.