J. Curtis McMillen

A compilation of strategies for implementing clinical innovations in health and mental health

Efforts to identify, develop, refine, and test strategies to disseminate and implement evidence-based treatments have been prioritized in order to improve the quality of health and mental health care delivery. However, this task is complicated by an implementation science literature characterized by inconsistent language use and inadequate descriptions of implementation strategies. This article brings more depth and clarity to implementation research and practice by presenting a consolidated compilation of discrete implementation strategies, based on a review of 205 sources published between 1995 and 2011. The resulting compilation includes 68 implementation strategies and definitions, which are grouped according to six key implementation processes: planning, educating, financing, restructuring, managing quality, and attending to the policy context. This consolidated compilation can serve as a reference to stakeholders who wish to implement clinical innovations in health and mental health care and can facilitate the development of multifaceted, multilevel implementation plans that are tailored to local contexts.

Implementation strategies: Recommendations for specifying and reporting

Implementation strategies have unparalleled importance in implementation science, as they constitute the ‘how to’ component of changing healthcare practice. Yet, implementation researchers and other stakeholders are not able to fully utilize the findings of studies focusing on implementation strategies because they are often inconsistently labelled and poorly described, are rarely justified theoretically, lack operational definitions or manuals to guide their use, and are part of ‘packaged’ approaches whose specific elements are poorly understood. We address the challenges of specifying and reporting implementation strategies encountered by researchers who design, conduct, and report research on implementation strategies. Specifically, we propose guidelines for naming, defining, and operationalizing implementation strategies in terms of seven dimensions: actor, the action, action targets, temporality, dose, implementation outcomes addressed, and theoretical justification. Ultimately, implementation strategies cannot be used in practice or tested in research without a full description of their components and how they should be used. As with all intervention research, their descriptions must be precise enough to enable measurement and ‘reproducibility.’ We propose these recommendations to improve the reporting of implementation strategies in research studies and to stimulate further identification of elements pertinent to implementation strategies that should be included in reporting guidelines for implementation strategies.

What parts of PTSD are normal: intrusion, avoidance, or arousal? Data from the Northridge, California, earthquake.

The incidence and comorbidity of posttraumatic stress disorder (PTSD) are addressed in a study of 130 Northridge, California, earthquake survivors interviewed 3 months postdisaster. Only 13% of the sample met full PTSD criteria, but 48% met both the reexperiencing and the arousal symptom criteria, without meeting the avoidance and numbing symptom criterion. Psychiatric comorbidity was associated mostly with avoidance and numbing symptoms. For moderately severe traumatic events, reexperiencing and arousal symptoms may be the most “normal,” and survivors with a history of psychiatric problems may be those most likely to develop full PTSD. A system that considers people who meet all three symptom criteria to have a psychiatric disorder yet recognizes the distress of other symptomatic survivors may best serve traumatized populations.

Coping, functioning, and adjustment of rescue workers after the Oklahoma City bombing

Studies have not previously considered postdisaster adjustment in the context of psychiatric disorders. After the Oklahoma City bombing, a volunteer sample of 181 firefighters who served as rescue and recovery workers was assessed with a structured diagnostic interview. The firefighters had relatively low rates of posttraumatic stress disorder (PTSD) and described little functional impairment, positive social adjustment, and high job satisfaction. PTSD was associated with reduced job satisfaction and functional impairment, providing diagnostic validity. Turning to social supports, seeking mental health treatment, and taking medication were not widely prevalent coping responses. Postdisaster alcohol use disorders and drinking to cope were significantly associated with indicators of poorer functioning. Surveillance for problem drinking after disaster exposure may identify useful directions for intervention.

Pediatric to Adult Mental Health Service Use of Young People Leaving the Foster Care System

PURPOSE To assess and predict changes in mental health service use as older youth leave the foster care system. METHODS Participants were 325 19-year-olds participating in a longitudinal study of older youth leaving the foster care system in Missouri. All were in the foster care system at age 17. Participants were interviewed nine times between their 17th and 19th birthdays using the Service Assessment for Children and Adolescents and a history calendar to improve recall of service history. Analyses included Cox proportional hazards regression to predict time to service stoppage and McNemars test to assess difference in rates of service use between age 17 and 19. RESULTS Mental health service use dropped dramatically across the study period for all services. Service rates dropped most steeply for youth who left the foster care system. Service use rates declined by roughly 60% from the month prior to leaving the foster care system to the month after leaving the system. Most young adults who stopped pharmacotherapy following discharge from foster care reported they did so of their own volition. CONCLUSIONS Practitioners should be aware of the possibility of patient-initiated mental health service discontinuation following exit from the foster care system and plan accordingly.

Mental Health Problems and Sexual Abuse Among Adolescents in Foster Care: Relationship to HIV Risk Behaviors and Intentions

Adolescents in foster care present with multiple psychosocial and mental health problems that individually are associated with increased risk for HIV infection. However, few studies have examined empirically the interrelationships among these problems and HIV risk behaviors in this population. This study examined the sexual abuse histories and mental health problems among 343 youths in foster care to determine their association with HIV-risk behaviors and behavioral intentions. Results indicated that 25% reported internalizing behaviors (withdrawn, somatic complaints, depressed) and 28.3% reported externalizing behaviors (delinquent and aggressive behaviors). Of the sample, 37% reported some form of prior sexual abuse. Multivariate analyses using simultaneous entry of variables indicated that controlling for demographic variables and behavioral intentions, externalizing behaviors showed the strongest relationship with HIV-risk behaviors. Likewise, in the multivariate model, it was most strongly associated with behavioral intentions. Moreover, there was a significant race-by-gender interaction, with White females engaging in more risky behaviors than their male counterparts and youths of color.

Ending Social Work's Grudge Match: Problems Versus Strengths

Some in social work have called for a paradigm shift away from a focus on problems to a focus on strengths, empowerment, and capacity building. This call sets up an unnatural dichotomy, asking social workers to identify with one side or another. In this article, we review social work history to argue that the best social work practice has always maintained a dual focus on both problems and capacity building. Throughout our history, those who championed a problem-oriented practice also emphasized strengths and growing client capacity, and todays strength-based, capacity-oriented practitioners typically advocate for the solving of consumers presenting problems.

Methods to Improve the Selection and Tailoring of Implementation Strategies

Implementing behavioral health interventions is a complicated process. It has been suggested that implementation strategies should be selected and tailored to address the contextual needs of a given change effort; however, there is limited guidance as to how to do this. This article proposes four methods (concept mapping, group model building, conjoint analysis, and intervention mapping) that could be used to match implementation strategies to identified barriers and facilitators for a particular evidence-based practice or process change being implemented in a given setting. Each method is reviewed, examples of their use are provided, and their strengths and weaknesses are discussed. The discussion includes suggestions for future research pertaining to implementation strategies and highlights these methods’ relevance to behavioral health services and research.

Aging Out of Foster Care and Legal Involvement: Toward a Typology of Risk

This article uses data from a study funded by the National Institute of Mental Health to explore variation in the risk of legal involvement among youths who have aged out of the child welfare system. Employing latent class analysis, it empirically derives subgroups of youths with common or shared characteristics of risk. The analyses identify four distinct subgroups: the low‐risk, moderate‐risk, high‐risk externalizing psychopathology, and high‐risk drug culture groups. Multinomial logistic regressions show that contextual and dispositional factors predict group membership. Attention to the factors that distinguish the groups may attenuate the risk for legal involvement for youths aging out of the child welfare system.

Revisiting Practice-Based Research Networks as a Platform for Mental Health Services Research

Practice-based research networks (PBRNs)—collaborations of practice settings that work together to generate research knowledge—are underused in mental health services research. This article proposes an agenda for mental health services research that uses a variety of PBRN structures and that focuses on what really happens in practice, the effectiveness of practice innovations in real world care, the challenges of implementing evidence supported interventions, modification of clinician behavior, and assessment of the effect of mental health policy changes on practice. The challenges of conducting research within PBRNs are substantial, including difficulties in maintaining positive member relations, securing ongoing funding, sustaining productivity, overcoming IRB entanglements and achieving both scientific excellence in recruitment and measurement validity and utility for practitioner members. However, the awareness of these challenges allows researchers and practitioners to build networks that creatively overcome them and that infuse mental health services research with heavy doses of the realities of everyday clinical practice.