Mutual Help Groups for Mental Health Problems: A Review of Effectiveness Studies

This paper reviews empirical studies on whether participating in mutual help groups for people with mental health problems leads to improved psychological and social functioning. To be included, studies had to satisfy four sets of criteria, covering: (1) characteristics of the group, (2) target problems, (3) outcome measures, and (4) research design. The 12 studies meeting these criteria provide limited but promising evidence that mutual help groups benefit people with three types of problems: chronic mental illness, depression/anxiety, and bereavement. Seven studies reported positive changes for those attending support groups. The strongest findings come from two randomized trials showing that the outcomes of mutual help groups were equivalent to those of substantially more costly professional interventions. Five of the 12 studies found no differences in mental health outcomes between mutual help group members and non-members; no studies showed evidence of negative effects. There was no indication that mutual help groups were differentially effective for certain types of problems. The studies varied in terms of design quality and reporting of results. More high-quality outcome research is needed to evaluate the effectiveness of mutual help groups across the spectrum of mental health problems.     

Brief Parenting Interventions for Children at Risk of Externalizing Behavior Problems: A Systematic Review

We systematically reviewed the evidence for the efficacy and effectiveness of brief parenting interventions, defined as <8 sessions in duration, in reducing child externalizing behaviors. While there is significant evidence to support the efficacy of parenting interventions of 8–12 sessions in duration, the public health benefit of these interventions is limited by low participation rates, high attrition rates and the lack of implementation by a wide range of practitioners. Brief parenting interventions have the potential to extend the reach and impact of parenting interventions and steer children away from a trajectory of life course persistent behavior problems. A search of four electronic databases was undertaken to identify RCTs conducted on brief parenting interventions. The primary outcome was child externalizing behaviors and secondary outcomes included parenting skills, parental self-efficacy, parental mental health and partner relationship functioning. The heterogeneity of included studies prevented a meta-analysis but characteristics of the studies were described. Nine papers summarising the results of eight studies with 836 families in five countries met inclusion criteria. All studies found significant improvements in parent-rated child externalizing behaviors, parenting skills and parenting self-efficacy, relative to control or comparison groups, with findings maintained at follow-up. Less consistent findings emerged for parental mental health and partner relationship functioning. This review provides initial evidence that brief parenting interventions may be sufficient to reduce child externalizing behavior problems for some families, however further research is needed.     

School-Based Mental Health Services: A Research Review

This paper provides a synthetic review of research on school-based mental health services. Schools play an increasingly important role in providing mental health services to children, yet most school-based programs being provided have no evidence to support their impact. A computerized search of references published between 1985 and 1999 was used to identify studies of school-based mental health services for children. Study inclusion was determined by (i) use of randomized, quasi-experimental, or multiple baseline research design; (ii) inclusion of a control group; (iii) use of standardized outcome measures; and (iv) baseline and postintervention outcome assessment. The application of these criteria yielded a final sample of 47 studies on which this review is based. Results suggest that there are a strong group of school-based mental health programs that have evidence of impact across a range of emotional and behavioral problems. However, there were no programs that specifically targeted particular clinical syndromes. Important features of the implementation process that increase the probability of service sustainability and maintenance were identified. These include (i) consistent program implementation; (ii) inclusion of parents, teachers, or peers; (iii) use of multiple modalities; (iv) integration of program content into general classroom curriculum; and (v) developmentally appropriate program components. Implications of these findings and directions for future research are discussed.     

Counting the stitches that count: Preventive intervention promises and public health

Continued public support for the design, implementation, and dissemination of preventive interventions depends on achievement of four major criteria: (a) Reductions in the incidence or prevalence rates of diagnosable emotional and behavioral disorders, (b) reductions in the need for mental health services through effective primary and secondary interventions, (c) enhancement of the effectiveness of obtained services as screening and early detection efforts are implemented, and (d) reductions in the nation's health care costs associated with emotional and behavioral dysfunctions. Strategies including risk reduction, risk avoidance, health promotion, empowerment, and resource development are preventive insofar as they contribute to achievement of the aforementioned outcomes.     

Differential Effectiveness of Behavioral Parent-Training and Cognitive-Behavioral Therapy for Antisocial Youth: A Meta-Analysis

Extended the findings from previous meta-analytic work by comparing the effectiveness of behavioral parent-training (BPT) and cognitive-behavioral therapy (CBT) for youth with antisocial behavior problems. Youth demographic variables were also examined as potential moderators of the effectiveness of these 2 types of interventions. Thirty BPT studies and 41 CBT studies met inclusion criteria for this meta-analysis. The weighted mean effect size (ES) for all interventions was 0.40. Youth age was found to moderate the outcome of the 2 interventions, with BPT having a stronger effect for preschool and school-aged youth and CBT having a stronger effect for adolescents. The results also indicate that there may be systematic differences in the outcomes associated with BPT and CBT when the setting of the intervention is considered, suggesting the need to carefully consider the effect of setting in future research. This study also highlights the need for outcome research dealing with more diverse populations and the better classification of research participants on different developmental trajectories of antisocial behavior.     

Behavioral Activation Disseminated by Non–Mental Health Professionals,Paraprofessionals, and Peers: A Systematic Review

There is a striking disparity between the number of individuals with significant mental health concerns and those who are able to access care globally. One promising solution to expanding the mental health taskforce is task-sharing, or employing nonspecialists in the delivery of evidence-based interventions. Behavioral activation (BA), a brief intervention that focuses on scheduling rewarding activities into one’s daily life, may have promise for delivery using task-sharing approaches due to its straightforward, flexible nature. The aim of this systematic review was to examine the current state of the literature on non-specialist-delivered BA and evaluate the evidence base of this approach. Three databases (Pubmed, PsycInfo, and Cochrane) were searched, and all articles were screened for inclusion criteria by two research assistants, included the review of titles, abstracts, and full-text. The final dataset consisted of 13 research studies, represented through 15 articles. A meta-analysis was conducted to examine the overall pooled effects of peer-delivered BA on depressive symptoms (the most widely examined clinical outcome). Studies reported on effectiveness and implementation outcomes of non-specialist-delivered BA for depression, substance use, loneliness, trauma survivors, and individuals with comorbid physical health conditions. Results provide initial support for the effectiveness of BA utilizing a task-sharing approach, and highlight the feasibility and acceptability of using nonspecialists to deliver BA in a variety of contexts, including low-resource settings.     

Benchmarking Treatment Effectiveness of Community‐Delivered Trauma‐Focused Cognitive Behavioral Therapy

It is critical for urban youth with post‐traumatic stress disorder (PTSD) living in poverty to have access to evidence‐based interventions for their traumatic stress. However, there is limited research on the effectiveness of these interventions when provided in urban, community settings. The objectives of the current study are to (a) evaluate the effectiveness of trauma‐focused cognitive behavioral therapy delivered from 2013 to 2016 in 15 behavioral health agencies on youth (N = 114) PTSD as well as  general mental health symptoms and  functioning, and (b) benchmark these clinical outcomes against other published efficacy and effectiveness trials. Effectiveness data are from the Philadelphia County Community Behavioral Health System, a system that has invested significantly in the training and ongoing support of clinicians providing high‐quality trauma services to youth since 2012. From baseline to last assessment, youth PTSD symptom severity (d = 0.34), PTSD functional impairment (d = 0.38), and overall mental health problem severity (d = 0.29) improved. The effect sizes of  improvements were smaller than effect sizes observed in efficacy and effectiveness studies. This study is the first benchmarking study of TF‐CBT and provides preliminary findings with regard to the effectiveness, and transportability, of TF‐CBT to urban community settings that serve youth in poverty.     

A descriptive analysis of client outcomes associated with staff interventions in developmental disabilities

Although a large body of research supports the use of behavioral staff management interventions in developmental disabilities, the nature of client outcomes associated with such interventions has not been systematically assessed. We reviewed 59 staff management studies published over 20 years (1971–1990) in order to determine the generality or scope of the research (i. e., range of settings, types and levels of clients' disabilities, clients' ages), the frequency of inclusion of client outcome measures, the types of measures and levels of analysis selected (i. e., individual groups, combination), and the effects of the interventions on client behavior. Results indicated that: (a) over two-third of the studies were conducted in institutional settings; (b) more than one-half involved clients with profound to severe mental retardation; (c) clients of various ages were served; (d) assessment of client outcomes increased progressively over the period; (e) engagement and skill acquisition were the most frequently used measures; (f) group data were presented twice as frequently as either individual or a combination of group and individual data; and (g) staff interventions were associated with either positive or mixed client outcomes in 80% or more of the cases, although maladaptive behavior went unchanged in one-fifth of the studies in which they were reported. Based on these findings, suggestions are made for how researchers might extend the generality of staff management research, improve client outcome assessment practices, and produce even more consistently positive results.     

Stigma and Client Satisfaction in Mental Health Services

Numerous studies have revealed that stigmatization of persons with mental health problems has a large array of negative consequences. One outcome that has been largely neglected is client satisfaction. In this empirical study, the link between 3 types of stigma experiences and client satisfaction is explored in a sample of clients (N = 741) of professional mental health services in Belgium. This relationship is compared with the link between stigma and general life satisfaction; and the role of the self‐concept in these relationships is explored. The results reveal that the association depends on the dimension of stigma under study. The findings stress the importance of studying multiple dimensions of stigma experiences, in addition to multiple outcomes.     

The Effectiveness of Psychosocial Interventions Delivered by Teachers in Schools: A Systematic Review and Meta-Analysis

The growing mental health needs of students within schools have resulted in teachers increasing their involvement in the delivery of school-based, psychosocial interventions. Current research reports mixed findings concerning the effectiveness of psychosocial interventions delivered by teachers for mental health outcomes. This article presents a systematic review and meta-analysis that examined the effectiveness of school-based psychosocial interventions delivered by teachers on internalizing and externalizing outcomes and the moderating factors that influence treatment effects on these outcomes. Nine electronic databases, major journals, and gray literature (e.g., websites, conference abstract) were searched and field experts were contacted to locate additional studies. Twenty-four studies that met the study inclusion criteria were coded into internalizing or externalizing outcomes and further analyzed using robust variance estimation in meta-regression. Both publication and risk of bias of studies were further assessed. The results showed statistically significant reductions in students’ internalizing outcomes (d = .133, 95% CI [.002, .263]) and no statistical significant effect for externalizing outcomes (d = .15, 95% CI [?.037, .066]). Moderator analysis with meta-regression revealed that gender (%male, b = ?.017, p < .05), race (% Caucasian, b = .002, p < .05), and the tier of intervention (b = .299, p = .06) affected intervention effectiveness. This study builds on existing literature that shows that teacher-delivered Tier 1 interventions are effective interventions but also adds to this literature by showing that interventions are more effective with internalizing outcomes than on the externalizing outcomes. Moderator analysis also revealed treatments were more effective with female students for internalizing outcomes and more effective with Caucasian students for externalizing outcomes.     

Delivering effective children's services in the community: Reconsidering the benefits of system interventions

This article examines research on systems of care, which are acknowledged as the current dominant paradigm in the delivery of children's mental health services. The authors conclude that systems of care produce important system-level changes. Early results suggest that these systems changes do not impact clinical outcomes, however. One plausible explanation for this finding is that system interventions are too far removed from the actual delivered services, thereby limiting their potential impact. Moreover, numerous assumptions underlying the purported effectiveness of systems of care remain unvalidated. The authors propose that the primary direction to improving children's mental health services should be through effectiveness research, in contrast to continued large-scale investments in systems research and development. Recommendations are made for addressing methodological problems that researchers will confront and for developing policies encouraging future research on the effectiveness of children's mental health services.     

The Ohio Scales: Practical Outcome Assessment

The development and initial psychometric studies for the Ohio Youth Problems, Functioning, and Satisfaction Scales (Ohio Scales) are described. The Ohio Scales were developed to be practical yet rigorous, multi-content, multi-source measures of outcome for children and adolescents receiving mental health services. Initial studies suggest that the Ohio Scales are promising (reliable, valid, and sensitive to change) measures that can be used to track the effectiveness of mental health interventions for youth with serious emotional disorders. Additional studies are warranted to expand the situations and populations within which the scales are valid.     

Internet-delivered transdiagnostic and tailored cognitive behavioral therapy for anxiety and depression: a systematic review and meta-analysis of randomized controlled trials

Anxiety and depressive disorders are often comorbid. Transdiagnostic and tailored treatments seem to be promising approaches in dealing with comorbidity. Although several primary studies have examined the effects of Internet-delivered cognitive behavior therapy (iCBT) for anxiety and depression, no meta-analysis including different types of iCBT that address comorbidity has been conducted so far. We conducted systematic searches in databases up to 1 July 2016. Only randomized trials comparing transdiagnostic/tailored iCBT for adult anxiety and/or depression with control groups were included. Nineteen randomized trials with a total of 2952 participants that met inclusion criteria were analyzed. The quality of the studies was high, however the blinding criteria were not fulfilled. The uncontrolled effect size (Hedges’ g) of transdiagnostic/tailored iCBT on anxiety and depression outcomes was large and medium for quality of life. The controlled effect size for iCBT on anxiety and depression outcomes was medium to large (anxiety: g = .82, 95% CI: .58–1.05, depression: g = .79, 95% CI: .59–1.00) and medium on quality of life (g = .56, 95% CI: .37–.73). Heterogeneity was small (quality of life) to moderate (anxiety, depression). There was a large effect on generic outcome measures and a moderate effect on comorbidities. When compared to disorder-specific treatments there were no differences on anxiety and quality of life outcomes, however there were differences in depression outcomes. Transdiagnostic and tailored iCBT are effective interventions for anxiety disorders and depression. Future studies should investigate mechanisms of change and develop outcome measures for these interventions.     

Family Support in Prevention Programs for Children at Risk for Emotional/Behavioral Problems

We conducted a review of empirically based prevention programs to identify prevalence and types of family support services within these programs. A total of 238 articles published between 1990 and 2011 that included a family support component were identified; 37 met criteria for inclusion. Following the Institute of Medicine’s typology, prevention programs were categorized as universal, selective, or indicated; programs containing more than one prevention level were characterized as multi-level. Family support types included those led by a mental health professional, led by a peer, or team-led. Among the 37 prevention programs reviewed, 27% (n = 10) were universal, 41% (n = 15) were selective, 16% (n = 6) were indicated, and 16% (n = 6) were multi-level. The predominant model of family support was professionally led (95%, n = 35). Two (n = 5%) provided team-led services. None were purely peer-led. In terms of content of family support services, all (100%, n = 37) provided instruction/skill build. Information and education was provided by 70% (n = 26), followed by emotional support (n = 11, 30%) and instrumental or concrete assistance (n = 11, 30%). Only 14% (n = 5) provided assistance with advocacy. The distribution of models and content of services in prevention studies differ from family support within treatment studies. As family support is likely to be an enduring component of the child and family mental health service continuum, comparative effectiveness studies are needed to inform future development.     

The Role of Schools in Outcomes for Youth: Implications for Children's Mental Health Services Research

We explore the role of schools in children's mental health services research. Recent literature has suggested that schools play an important role in delivering services to children and adolescents with emotional and behavioral problems. Research in services research, though, has taken a fairly narrow view of which dimensions of school environments are relevant for inclusion in studies. We suggest that a broader view of school environments is appropriate and potentially beneficial to the field. Using Bronfenbrenner's ecological model as a guide, we conceptualize schools as microsystems. Such an approach suggests that all aspects of school environments (treatment as well as non-treatment) are likely to influence many of the outcomes that children's mental health services research frequently targets (e.g., behavioral problems, problematic peer relationships, academic achievement, school attendance). We review literature from a variety of disciplines to suggest relevant features of schools, with particular attention to the role of peer dynamics within schools. We conclude with implications of this expanded conceptualization of schools for children's mental health services research.     

Reply by Edward S. Casey

Stigma and discrimination against mental illness represent chronic social stressors that can inflame psychiatric symptoms and limit functional adjustment. The implication is that the prevalence and severity of mental illness is determined, at least to a certain extent, by aversive socio-cultural factors. In a hostile social environment, these factors may seriously limit the effectiveness of professional interventions; whereas, removing social barriers to functioning often results in a favorable clinical outcome. For example, studies show that inclusive settings with supportive employment decrease psychiatric symptoms and the use of mental health services. By extrapolation, these results point to the possibility that a society-wide reduction in the prevalence and severity of mental illness may come from benevolent changes in the social climate, not just from innovative treatments. Public health policies rarely take this possibility into consideration in resource allocation decisions.     

Which preventive interventions effectively enhance depressed mothers' sensitivity? A meta‐analysis

Improving depressed mothers' sensitivity is assumed to be a key element in preventing adverse outcomes for children of such mothers. This meta‐analysis examines the short‐term effectiveness of preventive interventions in terms of enhancing depressed mothers' sensitivity toward their child and investigates what type of intervention is most effective. Thirteen interventions, reported in 10 controlled outcome studies, met the inclusion criteria (N = 918). Meta‐analytic results showed a small to medium, significant mean effect size (g = 0.32) with large variation in individual effect sizes (?0.56–1.76). Interventions including baby massage were highly effective in improving maternal sensitivity (g = 0.85). In contrast, individual therapy for the mother proved ineffective in terms of improving maternal sensitivity (g = ?0.00). Two other significant predictors of greater effect sizes were the inclusion of a support group and the use of a higher number of intervention methods; however, the significance of these results was largely accounted for by one single study. Our meta‐analysis confirms that depressed mothers' sensitivity can be improved by preventive intervention and suggests that baby massage may be an effective intervention method to evoke short‐term changes in maternal sensitivity. It is unclear whether these changes are maintained over time.     

Referrers' Perceived Utility and Outcomes of Clinical Neuropsychological Assessment in an Adolescent and Young Adult Public Mental Health Service

Despite frequent informal or anecdotal acknowledgement of the usefulness of neuropsychological services within various settings, including mental health settings, few studies have formally investigated the satisfaction, perceived utility, or outcomes associated with such a service. This survey‐based study evaluated referring clinicians’ (n = 35) perceptions of the usefulness and outcomes associated with the provision of clinical neuropsychological assessment and feedback within an adolescent and young adult public mental health service in Melbourne, Australia. The results suggest that referrers perceive the neuropsychological service, including formal neuropsychological assessment report and verbal and written feedbacks, as a highly useful adjunct to their clinical practice. In addition, referrers frequently reported clinically meaningful outcomes in association with the neuropsychological service, including diagnostic changes or additions (11% of clients referred), changes to approaches in treatment (52% of clients referred), and increased or appropriate access to services, education, or work (33% of clients referred). Referrers also reported that almost 60% of neuropsychological assessment reports were forwarded to other services or clinicians involved in the client's care. The findings suggest that mental health settings are likely to benefit from routine inclusion of specialist neuropsychology services. However, future research should also examine client and family perceptions regarding the satisfaction and usefulness of neuropsychological services.     

Mental Health Services in Juvenile Correctional Facilities: A National Survey of Clinical Staff

This study determined the use of best practices in providing mental health services to youth within juvenile correctional facilities. A national sample of 94 (49.7 %) lead clinical staff from all available and qualifying facilities responded to a mail and on-line survey. There were no statistically significant differences across respondents versus nonrespondents for security level, gender served, or census region of facilities. Specifically, we examined the provision of facility-wide mental health programming, individual, group, and family counseling, and case management services. Examination of these services included the use of evidence-based interventions provided through an established curriculum and methods used to evaluate the effectiveness of the interventions. We also examined staff involvement, and the perceived quality of services and barriers to providing interventions. Participants reported using a variety of evidence-based interventions; however, participants also acknowledged using other approaches that may not have empirical support. Additionally, although at least half of the participants reported mandatory individual and group counseling, less than a third of the participants reported that their facilities required family counseling. Clinical staff also reported a variety of methods used for evaluating the effectiveness of mental health services. Additional findings, as well as implications for research and practice, are discussed.     

Long Term Outcomes to Family Caregiver Empowerment

The Vanderbilt Caregiver Empowerment Project evaluated a training program designed to enhance empowerment of caregiver and their subsequent involvement in the mental health treatment of their children. The intervention utilized a multi-component parent training curriculum that was designed to enhance: (a) knowledge of the service system; (b) skills needed to interact with the mental health system; and (c) the caregiver' s mental health services self-efficacy designed to improve caregivers beliefs in their ability to collaborate with service providers. The resulting increased empowerment was hypothesized to increase caretaker involvement, which should affect service use and ultimately the mental health status of the child. A randomized design was used to test the effectiveness of this model with caregivers of children receiving mental health services. The results one-year after the training replicated the intermediate outcomes of the project conducted 3-months after the training. The initial training continued to significantly influence the parent's knowledge and mental health services self-efficacy. However, the intervention had no effect on caregiver involvement in treatment, service use or the mental health status of the children.