Evidence-based psychological treatments for disruptive behaviors in individuals with dementia

In this article, the authors review the literature regarding evidence-based psychological treatments (EBTs) for behavioral disturbances in older adults with dementia, as proposed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology. Fifty-seven randomized clinical trials were reviewed for inclusion on the basis of titles or abstract information. Forty-three were excluded either because they did not meet EBT methodological criteria or because they involved environmental or psychoeducational nursing interventions in which the psychological component could not be separately evaluated. Fourteen studies were considered for inclusion as EBTs; of these, 8 showed significant differences between treatment and control groups. Results of this review indicate that behavioral problem-solving therapies that identify and modify antecedents and consequences of problem behaviors and increase pleasant events and individualized interventions based on progressively lowered stress threshold models that include problem solving and environmental modification meet EBT criteria. Additional randomized clinical trials are needed to evaluate the generalizability and efficacy of these and other promising psychological interventions in a variety of settings with individuals who have a range of cognitive, functional, and physical strengths and limitations.     

When the Evidence Says, "Yes, No, and Maybe So": Attending to and Interpreting Inconsistent Findings Among Evidence-Based Interventions

ABSTRACT— An international, multidisciplinary effort aims to identify evidence-based treatments (EBTs) or interventions. The goal of this effort is to identify specific techniques or programs that successfully target and change specific behaviors. In clinical psychology, EBTs are identified based on the outcomes of randomized controlled trials examining whether treatments outperform control or alternative treatment conditions. Treatment outcomes are measured in multiple ways. Consistently, different ways of gauging outcomes yield inconsistent conclusions. Historically, EBT research has not accounted for these inconsistencies. In this paper we highlight the implications of inconsistencies, describe a framework for redressing inconsistent findings, and illustrate how the framework can guide future research on how to administer and combine treatments to maximize treatment effects and how to study treatments via quantitative review.     

Supervision in Community Mental Health: Understanding Intensity of EBT Focus

The goal of the present study was to examine clinician, supervisor, and organizational factors that are associated with the intensity of evidence-based treatment (EBT) focus in workplace-based clinical supervision of a specific EBT, Trauma-Focused Cognitive Behavioral Therapy (TF-CBT). Supervisors (n = 56) and clinicians (n = 207) from mental health organizations across Washington State completed online self-report questionnaires. Multilevel modeling (MLM) analyses were used to examine the relative influence of nested clinician and supervisor factors on the intensity of EBT focus in supervision. We found that 33% of the variance in clinician report of EBT supervision intensity clustered at the supervisor level and implementation climate was the only significant factor associated with EBT supervision intensity. While individual clinician and supervisor factors may play a role in EBT coverage in supervision, our results suggest that an implementation climate that supports EBT may be the most critical factor for improving intensity of EBT coverage. Thus, implementation efforts that address the extent to which EBTs are expected, rewarded, and supported within an organization may be needed to support greater coverage of EBT during workplace-based supervision.     

Applying a Process-Oriented Model of Cultural Competence to Behavioral Activation for Depression

Efforts to integrate cultural competence and evidence-based treatments (EBTs) typically take the form of cultural adaptations of EBTs, characterized by modifications to the existing treatment based on presumed cultural notions of a given race or ethnic group. Much less attention has been given to ways EBTs can integrate a process model of cultural competence, which focuses on what clinicians do in-session to identify and integrate key cultural factors for a given individual in the treatment. Our objective is to consider how a process model of cultural competence (Shifting Cultural Lenses) can be integrated with an EBT (Behavioral Activation). We present a theoretical rationale for integrating the SCL model with BA and illustrate this integration, which provides an additional approach to bringing culture to treatments and shows promise for identifying clinicians’ in-session behaviors that reflect cultural competence.     

Evidence-based psychological treatments for insomnia in older adults

The review describes evidence-based psychological treatments (EBTs) for insomnia in older adults. Following coding procedures developed by the American Psychological Association's Committee on Science and Practice of the Society for Clinical Psychology, two treatments were found to meet EBT criteria: sleep restriction-sleep compression therapy and multicomponent cognitive-behavioral therapy. One additional treatment (stimulus control therapy) partially met criteria, but further corroborating studies are needed. At the present time, there is insufficient evidence to consider other psychological treatments, including cognitive therapy, relaxation, and sleep hygiene education, as stand-alone interventions beneficial for treating insomnia in older adults. Additional research is also needed to examine the efficacy of alternative-complementary therapies, such as bright light therapy, exercise, and massage. This review highlights potential problems with using coding procedures proposed in the EBT coding manual when reviewing the existing insomnia literature. In particular, the classification of older adults as persons age 60 and older and the lack of rigorous consideration of medical comorbidities warrant discussion in the future.     

Economic Impact of the Statewide Implementation of an Evidence-Based Treatment: Multisystemic Therapy in New Mexico

Several states have made considerable investments into large-scale implementation of evidence-based treatments (EBTs), yet little is known about key success indicators for these implementation efforts such as cost and sustainability. To that end, the present study examined the economic impact of statewide implementation of multisystemic therapy (MST; Henggeler, Schoenwald, Borduin, Rowland, & Cuningham, 2009), a family- and community-based behavioral EBT for serious juvenile offenders in New Mexico. Participants were 1,869 youth who received MST across 23 teams during the study period. We conducted a cost-benefit analysis using metrics from state data sources that compared the cost of MST to its benefits (i.e., avoided expenses from pre- to posttreatment) in two domains: (a) behavioral health services (i.e., Medicaid claims) and (b) juvenile crime (i.e., taxpayer expenses, tangible and intangible expenses to crime victims). MST costs were based on Medicaid claims, which were reimbursed at an enhanced billing rate that was intended to cover expenses for both clinical and implementation (e.g., training, quality assurance) activities. Results suggest that implementation of MST in New Mexico over the 7-year study period may have produced net benefits, through 2 years posttreatment, of more than $4,643 per youth in avoided behavioral health claims and $15,019 per youth through reductions in juvenile crime. Stated differently, every dollar that New Mexico spent on MST appeared to have returned $3.34 for a total benefit of $64.2 million over the course of the study. We discuss implications of these findings for policymakers, administrators, and researchers who are interested in increasing the sustainability of complex EBTs in community settings.     

Core Elements of CBT for Adolescent Conduct and Substance Use Problems: Comorbidity,Clinical Techniques,and Case Examples

Adolescent externalizing problems (AEPs), including serious conduct problems, delinquency, and substance misuse, are the most common adolescent behavioral issues in specialty care. High rates of comorbidity between conduct and substance use problems necessitate multidomain treatment strategies that can effectively address the AEP spectrum. One strategy to increase delivery of evidence-based interventions for multiproblem youth in usual care is to focus on core elements of empirically supported treatments that can be judiciously applied to clients presenting with diverse clinical profiles. This paper describes six core practice elements of the cognitive-behavioral treatment (CBT) approach for AEPs: (a) functional analysis of behavior hroblems, (b) prosocial activity sampling, (c) cognitive monitoring and restructuring, (d) emotion regulation training, (e) problem-solving training, and (f) communication training. Integrated delivery of these core CBT elements is illustrated in two case examples, and implications for treatment planning for youth with AEPs are discussed.     

Commentary on Koons et al.’s (2013) “Negotiating for Improved Reimbursement for Dialectical Behavior Therapy: A Successful Project”

This paper provides a commentary of Koons, O’Rourke, Carter, and Erhardt (this issue), which takes an inspiring first step in bridging research and clinical practice. We encourage the field to take the following from this paper: (a) evidence-based treatment (EBT) can work in real-world settings; (b) publishable research can be accomplished in a purely clinical environment; (c) some insurance companies are willing to pay more for EBTs; and (d) getting sufficient pay for more time-consuming work has potential to help patients. Koons et al. found the crucial synthesis for all clinicians: In a purely clinical setting, research demonstrated that people got better and the providers were paid more for their work.     

Evidence-based psychological treatments for distress in family caregivers of older adults

This review identifies evidence-based psychological treatments (EBTs) for reducing distress, and improving well-being, of family members caring for an older relative with significant cognitive and/or physical impairment. Three categories of psychologically derived treatments met EBT criteria: psychoeducational programs (N = 14 studies), psychotherapy (N = 3 studies), and multicomponent interventions (N = 2 studies). Specifically, support within the psychoeducational category was found for skill-training programs focused on behavior management, depression management, and anger management and for the progressively lowered threshold model. Within the psychotherapy category, cognitive-behavioral therapy enjoys strong empirical support. Within the multicomponent category, programs using a combination of at least 2 distinct theoretical approaches (e.g., individual counseling and support group attendance) were also found to be effective. Suggestions for future research include the development of more well-integrated multicomponent approaches, greater inclusion of ethnically diverse family caregivers in research protocols, and greater incorporation of new technologies for treatment delivery.     

Client Report of Delivery of Common Elements in Usual Care and the Association to Satisfaction

Recently, scholars have advocated for the use of a new flexible approach to evidence-based practice through the use of “common elements”, which are treatment procedures that are utilized in a variety of evidence-based mental health interventions. The objective of this study was to describe the extent to which clinicians are using common elements of evidence-based treatment (EBT) in routine mental health care for children and if they are utilizing more of the elements associated with their client’s diagnosis. A second objective was to determine whether use of these elements was associated with client satisfaction. The Youth Services Survey was administered to a diverse sample of youth and their caregivers (total sample = 1075) to measure satisfaction with services and use of both talk-based and skill-based common elements. More than 74 % of caregivers indicated that their child’s clinician utilized the talk-based common elements frequently or almost always. Additionally, at least 69 % of youth agreed with this finding. Youth and caregivers reported that the common elements related to skill building were utilized less frequently. A Generalized Estimating Equation approach was used to examine the relationship between use of common elements and client diagnosis and satisfaction. The results for diagnosis were mixed and varied by parent and youth report. Finally, the more clinicians discussed and practiced common elements of EBT with their clients, both youth and caregivers were more likely to be satisfied. Due to clients’ reporting that on average clinicians utilized skill building common elements less often, targeted clinician training may be important, since practicing skill-building therapeutic elements is key to adopting new methods of managing behavior and emotions. Further, if families are more satisfied with a common elements approach, then clinicians may be more likely to utilize it.     

Psychological therapy in primary care: work in progress

This paper considers the benefits to the mental health of patients of the provision of psychological services in primary care. I describe by means of context, the development of such a service over the last 7 years. In the following section I discuss the question of who is 'the patient' who gets referred and who can benefit from psychological treatment in a primary care setting. More specifically I consider the spectrum of psychopathology of patients who are referred in primary care for psychological help and in relation to this question I discuss what would constitute a meaningful clinical intervention. In the last section, I look at the question of what needs to be in place for a successful psychological service in a primary care setting. I argue that, while benefits for mild to moderate psychological problems have been documented by research findings, clinical scrutiny of the interventions in primary care suggest that this is not necessarily the case when it comes to patients with more severe psychological problems. I further argue that there are still important issues to be considered and researched and structures to be put into place before we can safeguard the clinical effectiveness of psychological interventions in primary care.     

Evidence-based treatments for adolescents with cannabis use disorders in the Spanish Public Health System

The goal of the present study is to describe the implementation of two Evidence-based treatments (EBT) for adolescent Cannabis Use Disorders (CUD) in the Spanish Public Health System, and its main clinical outcomes. Adolescent Community Reinforcement Approach (A-CRA) and Contingency Management (CM) were chosen as the most efficacious treatment programs for this population. A total of 26 adolescent cannabis users entered the study (91.7% male; age = 16.50) at two outpatient clinical facilities in Spain. A quasi-experimental design was utilized, with one group receiving A-CRA only and the other A-CRA + CM. Implementation of both EBTs resulted feasible, with positive clinical outcomes. Results indicated that A-CRA has positive retention (81.3%) and abstinence rates (68.8%). Results for the group receiving A-CRA + CM were not significantly better than A-CRA in retention (100%) or abstinence (75.5%), although sample is too small to establish firm conclusions. Cannabis-related problems and depressive symptomatology also decreased during treatment. Several limitations prevent us from determining the clinical efficacy of A-CRA in this study. The process of translating EBT's to clinical contexts presented with many difficulties that need to be overcome. Recommendations are made for further attempts to implement EBTs in these contexts.     

Implementation and Dissemination of Military Informed and Evidence-Based Interventions for Community Dwelling Military Families

Community dwelling military families from the National Guard and Reserve contend with deployment-related stressors in relative isolation, living in communities where mental health providers may have little knowledge of military culture. When they are community residents, active duty service members and families tend to live in close proximity to their military installations. This article will focus primarily on the challenges to quality mental health care for reserve component (RC) families. Where studies of RC families are absent, those of active component (AC) families will be highlighted as relevant. Upon completion of a deployment, reintegration for RC families is complicated by high rates of symptomatology, low service utilization, and greater barriers to care relative to AC families. A paucity of providers skilled in evidence-based treatments (EBTs) limits community mental health capacity to serve RC military families. Several emergent programs illustrate the potential for better serving community dwelling military families. Approaches include behavioral health homes, EBTs and treatment components, structured resiliency and parent training, military informed schools, outreach methods, and technology-based coping, and psychoeducation. Methods from implementation science to improve clinical skill acquisition and spread and sustainability of EBTs may advance access to and quality of mental health treatment and are reviewed herein. Recommendations related to research methods, military knowledge and treatment competencies, and transition to a public health model of service delivery are discussed.     

Brief Behavioral Therapy for Pediatric Anxiety and Depression: Piloting an Integrated Treatment Approach

Mood and anxiety disorders in youth are disabling, distressing, and prevalent. Furthermore, depression and anxiety frequently co-exist, may share several etiological factors, and respond to similar interventions. In this paper, we report preliminary results from a treatment adaptation project designed to condense existing cognitive behavioral therapy protocols for anxiety and depression to their core components and combine them into a brief, integrated treatment suitable for the broad population of internalizing youth seen in primary care. Specifically, we discuss: (a) the rationale for targeting anxiety and depression in pediatric primary care and the deployment-focused treatment development model; (b) the content of our behaviorally based treatment program; and (c) clinical outcomes of 2 sample cases with comorbid depression and anxiety.     

Using a Videogame Intervention to Reduce Anxiety and Externalizing Problems among Youths in Residential Care: an Initial Randomized Controlled Trial

Residential care is among the most intensive forms of treatment in youth care. It serves youths with severe behavioral problems and is primarily focused on targeting externalizing problems. Despite best efforts, effect sizes remain moderate, which may be due to the disregarding of internalizing symptoms – in particular anxiety - and to limitations regarding the delivery model of interventions. This initial randomized controlled trial (n?=?37) aimed to examine the effectiveness of a biofeedback videogame intervention (Dojo) as an addition to treatment as usual for youths with and without intellectual disability (ID) in residential care with clinical levels of anxiety and externalizing problems. Dojo targets both anxiety and externalizing problems, and incorporates the principles of conventional treatment, while addressing its limitations. Youths were randomly assigned to play Dojo (eight 30-min gameplay sessions) or to treatment as usual (TAU). Measurements of anxiety and externalizing problems were conducted at baseline, posttreatment, and 4-months follow-up through youths’ self-report and mentor-report. Completers-only analyses revealed decreases in self-reported anxiety and externalizing problems, and mentor-reported anxiety at posttreatment for participants in the Dojo condition compared to the control condition. Only mentor-reported anxiety was maintained at follow-up. No effect was found for mentor-reported externalizing problems. These findings provided preliminary evidence that Dojo is a promising, innovative intervention that engages high-risk youths. Practical implications are discussed.     

The experiences of gender diverse and trans children and youth considering and initiating medical interventions in Canadian gender-affirming speciality clinics

Abstract

Background: Canadian specialty clinics offering gender-affirming care to trans and gender diverse children and youth have observed a significant increase in referrals in recent years, but there is a lack of information about the experiences of young people receiving care. Furthermore, treatment protocols governing access to gender-affirming medical interventions remain a topic of debate.

Aims: This qualitative research aims to develop a deeper understanding of experiences of trans youth seeking and receiving gender-affirming care at Canadian specialty clinics, including their goals in accessing care, feelings about care and medical interventions they have undergone, and whether they have any regrets about these interventions.

Methods: The study uses an adapted Grounded Theory methodology from social determinants of health perspective. Thirty-five trans and gender diverse young people aged 9 to 17?years were recruited to participate in semi-structured interviews through the specialty clinics where they had received or were waiting for gender-affirming medical interventions such as puberty blockers, hormone therapy, and surgery.

Results: Young people felt positively overall about the care they had received and the medical interventions they had undergone, with many recounting an improvement in their well-being since starting care. Most commonly shared frustrations concerned delays in accessing interventions due to clinic waiting lists or treatment protocols. Some youth described unwanted medication side-effects and others said they had questioned their transition trajectory at certain moments in the past, but none regretted their choice to undergo the interventions.

Discussion: The results suggest that trans youth and gender diverse children are benefiting from medical gender-affirming care they receive at specialty clinics, providing valuable insight into their decision-making processes in seeking care and specific interventions. Providers might consider adjusting aspects of treatment protocols (such as age restrictions, puberty stage, or mental health assessments) or applying them on a more flexible, case-by-case basis to reduce barriers to access.     

Involving Parents in Indicated Early Intervention for Childhood PTSD Following Accidental Injury

Accidental injuries represent the most common type of traumatic event to which a youth is likely to be exposed. While the majority of youth who experience an accidental injury will recover spontaneously, a significant proportion will go on to develop Post-Traumatic Stress Disorder (PTSD). And yet, there is little published treatment outcome research in this area. This review focuses on two key issues within the child PTSD literature—namely the role of parents in treatment and the timing of intervention. The issue of parental involvement in the treatment of child PTSD is a question that is increasingly being recognized as important. In addition, the need to find a balance between providing early intervention to at risk youth while avoiding providing treatment to those youth who will recover spontaneously has yet to be addressed. This paper outlines the rationale for and the development of a trauma-focused CBT protocol with separate parent and child programs, for use with children and adolescents experiencing PTSD following an accidental injury. The protocol is embedded within an indicated intervention framework, allowing for the early identification of youth at risk within a medical setting. Two case studies are presented in order to illustrate key issues raised in the review, implementation of the interventions, and the challenges involved.     

Law enforcement preferences for PTSD treatment and crisis management alternatives

Evidence-based treatments (EBT) for posttraumatic stress disorder (PTSD) remain underutilized. Analog research, however, indicates that patients may be more amenable to receiving EBT for PTSD than utilization rates suggest. This study sought to extend previous studies by investigating PTSD treatment preferences among law enforcement individuals (i.e., active duty officers, cadets, criminal justice students). We asked 379 participants, with varying trauma histories, to read a police traumatic event and imagine they had developed PTSD. Participants rated the credibility of six treatment options which they might encounter in a treatment setting, and chose their most and least preferred treatments. Next, they evaluated a widely used debriefing intervention aimed at preventing PTSD. Almost 90% of participants chose exposure or Cognitive Processing Therapy as their first or second most preferred treatment, and they rated these interventions as significantly more credible than the other four treatment options. The sample showed ambivalence regarding the perceived efficacy of debriefing but found the rationale credible. This study supports previous analog research indicating that patients may be more interested in EBT than indicated by utilization rates, and suggests that law enforcement departments should consider offering EBT to officers who develop PTSD.     

The treatment of depression in older adults in the primary care setting: an evidence-based review.

The objective of this study was to conduct an evidence-based review of treatments for depression in older adults in the primary care setting. A literature search was conducted using PsycINFO and Medline to identify relevant, English language studies published from January 1994 to April 2004 with samples aged 55 and older. Studies were required to be randomized controlled trials that compared psychosocial interventions conducted within the primary care setting with "usual care" conditions. Eight studies with older adult samples met inclusion criteria and were included in the review. Two treatment models were evident: Geriatric Evaluation Management (GEM) clinics and an approach labeled integrated health care models. Support was found for each model, with improvement in depressive symptoms and better outcomes than usual care; however, findings varied by depression severity, and interventions were difficult to compare. Further efforts to improve research and clinical care of depression in the primary care setting for older adults are needed. The authors recommend the use of interdisciplinary teams and more implementation of psychosocial treatments shown to be effective for older adults.