Big collaborations for more effective psychology

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When Rinad Beidas, PhD, was completing her doctorate at the Temple University Child and Adolescent Anxiety Disorders Clinic in the mid-2000s, she noticed a pattern that “kept me up at night,” as she put it. Children who came to the research-based clinic said they were afraid that therapy wasn’t going to work; they had tried it before, but they remained as anxious as ever.

Beidas gleaned that often when these children had been treated in the community, they hadn’t received the gold-standard evidence-based treatment for pediatric anxiety: individualized cognitive behavioral therapy (CBT). She wanted to fix that.

“I developed a passion for and commitment to radically transforming mental health so it aligns with the deep evidence base that we have,” said Beidas, now an associate professor at the University of Pennsylvania (Penn).

Today, she is realizing that calling on a much larger scale, including working to improve uptake of evidence-based practices throughout Philadelphia’s community mental health system. She’s also coleading one of 11 ALACRITY (Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness) Research Centers, funded by the National Institute of Mental Health (NIMH) to foster innovation and accelerate the translation of research into clinical practice.

Beidas is one of a number of psychologists committed to making the growing field of implementation science a success story for mental and physical health. The work poses more challenges than traditional research because it entails working closely with front-line clinicians and agencies who are doing the best that they can to implement evidence-based practices in the face of real-world barriers including inadequate funding, challenging organizational climates, and lack of training. An additional challenge is that behavioral treatments are harder to implement than medical treatments because they are often more complex and nuanced.

“There was a time when we thought that if we just did the research and dropped it off at the river’s edge, others would pick it up,” said psychologist William T. Riley, PhD, director of the Office of Behavioral and Social Sciences Research at the National Institutes of Health (NIH). “The movement toward implementation has allowed us to reach further than that—to think not only about whether an intervention is efficacious or effective, but to look at barriers to implementation and how to overcome those. That’s become more of a research process in the field, and I think it’s been a really useful direction.”

That said, dissemination and implementation grants remain a small percentage of the overall NIH research portfolio, and most funding still goes to discovery-based grants. Nevertheless, “NIH will continue to fund this work because it’s clearly of value,” said Riley. “It increases the likelihood that all the research we’re doing will actually get implemented in practice, which is what we’re all about.”

Given this backdrop, a number of large-scale, longitudinal efforts show what is possible in the domain of implementation science and translational research. One is a comprehensive, far-reaching effort aimed at improving care for young people with first-episode psychosis. Starting with a handful of early psychosis treatment programs in the early 2000s, this work has grown to include more than 300 programs across the country using a model called coordinated specialty care, which is now considered the standard of practice for early psychosis in the United States. Recently, this work has added a new component called EPINET (Early Psychosis Intervention Network) that systematically collects de-identified data from coordinated specialty care programs nationwide, combines these data, and uses them to create a national learning system for early psychosis. (Learning health care, of which this effort is an example, is an aspirational goal for health systems “in which science, informatics, incentives, and culture are aligned for continuous improvement and innovation,” according to the National Academy of Medicine.)

The overall effort began in 2008 with a project sponsored by NIMH called RAISE (Recovery After an Initial Schizophrenia Episode). The program official who led this initiative—psychologist Robert K. Heinssen, PhD, ABPP, director of NIMH’s Division of Services and Intervention Research—was studying successes in Australia, Europe, and elsewhere that used comprehensive wraparound services to find and treat young people with early psychosis as soon as possible. These included intensive medical management and mental health services, as well as ongoing supports related to social and family functioning, relationships, work, and school.

To make this type of intervention work in the United States, Heinssen thought it imperative that it be viable in actual practice settings—that it could translate effectively into systems that were underresourced and lacked provider training.

“The challenge we posed to investigators was asking them to conduct a study of early intervention in community treatment centers rather than in academic research clinics—that took into account characteristics of the real-world patients, providers, and settings where these services would be implemented,” Heinssen said.

RAISE research found that this kind of practice-level implementation was possible. A study headed by psychiatrist John M. Kane, MD, of the Feinstein Institutes for Medical Research, found that among 404 patients across 34 community sites, those who received coordinated specialty care stayed in treatment longer, had greater improvement in psychiatric symptoms and quality of life, and were more fully engaged in work and school than those in usual care (The American Journal of Psychiatry, Vol. 173, No. 4, 2016).

A second study headed by psychiatrist Lisa B. Dixon, MD, MPH, of Columbia University, investigated and addressed barriers to implementing this care in New York and Maryland. It involved the commissioners of mental health in those states as coinvestigators to ensure that the treatment could be implemented and sustained within their existing mental health systems. That study, too, showed positive clinical outcomes and produced a suite of practice-based tools, manuals, and other resources for implementing coordinated specialty care programs in similar public health settings across the country (Annual Review of Clinical Psychology, Vol. 14, 2018).

Fortuitously, these research efforts intersected with a strong congressional interest in addressing early psychosis, given estimates that untreated psychosis was costing the U.S. economy some $155.7 billion a year in direct health care costs, unemployment, and lost productivity for caregivers (Cloutier, M., et al., Journal of Clinical Psychiatry, Vol. 77, No. 6, 2016).

Starting in 2014, Congress increased funding for the community mental health block grant program administered by the Substance Abuse and Mental Health Services Administration to implement evidence-based early psychosis treatment programs like those demonstrated to be effective by RAISE. Congress continues to appropriate funds annually for this purpose, investing more than $300 million since 2014.

The most recent phase of this work began in 2018, when Heinssen and psychologist Susan T. Azrin, PhD, chief of NIMH’s Early Psychosis Prediction and Prevention Unit, launched EPINET, the country’s first learning health care system for people with serious mental illness. NIMH awarded the first EPINET grants in the fall of 2019, funding five regional scientific hubs and a national data coordinating center, and it added three more hubs a year later. EPINET now has eight regional scientific hubs, which include 101 coordinated specialty care programs in 17 states, serving tens of thousands of young people with early psychosis.

EPINET’s mission, said Azrin, is to accelerate advances in early psychosis care, patient recovery outcomes, and scientific discovery via a national early psychosis learning health system. Here’s how it works: All EPINET clinics collect standardized, patient-level data using a core assessment battery that measures treatment characteristics, symptoms, recovery outcomes, and other factors important to the treatment and outcome of patients with early psychosis. Individual hubs then submit deidentified data to the EPINET National Data Coordinating Center, where analysts synthesize and aggregate it into a large data set representing thousands of patients who are followed over the course of their treatment.

There are many uses for the data, says Azrin, but a central one is rapidly feeding the data back to clinics so they can view their performance compared with national metrics, with their own previous data, and with data from other clinics, thus supporting quality improvement efforts. This large-scale data set will also help identify systemic gaps in early psychosis care and provide opportunities for improving treatments and generating new research, she says.

“EPINET is a forward-looking platform for studying early psychosis care—how to personalize it and how to improve it,” said Azrin. “NIMH is committed to generating the knowledge and the practice tools that support these young people’s recovery.”

Psychologists are also studying full-scale implementation of evidence-based programs in the public behavioral health system in Philadelphia, an effort that began in 2007, when Arthur C. Evans Jr., PhD, now APA’s chief executive officer, headed the Department of Behavioral Health and Intellectual disAbility Services there. Since then, psychologists and other researchers have been collaborating with providers and other community partners to implement evidence-based practices within that system, with the goals of improving outcomes, championing recovery, and decreasing health disparities. In 2013, the Evidence-Based Practice and Innovation Center was created to support these efforts in a centralized way.

Beidas has been involved in this work for a number of years as a research partner and evaluator. To date, these efforts—which now involve some 200 clinics throughout the city—show positive, if modest, results. In analyzing three waves of data gleaned from 340 providers at 20 clinics, Beidas and colleagues found a 6% increase in clinician self-reported use of CBT—the evidence-based treatment in which they received training—over 5 years. The more training and ongoing support that clinicians received, the more likely they were to report using CBT, with a 9% increase in use among those who took part in three or more trainings, the team found (Implementation Science, Vol. 14, No. 1, 2019).

To determine why more clinicians weren’t using CBT, Beidas and colleagues have since gone on to conduct extensive surveys and interviews with agency leaders and clinicians, findings they spelled out in an issue brief for Penn’s Leonard Davis Institute of Health Economics (Vol. 23, No. 5, 2020).

One overarching barrier to implementation, they found, related to finances. Agency leaders talked about struggling to make ends meet and the challenges of trying to deliver high-quality care in the context of inadequate resources. Clinicians’ personal financial situations were also a problem. Many are master’s-level therapists who receive scant pay, which in turn is related to high rates of turnover. The Philadelphia system, for example, loses 24% of its clinicians each year. What’s more, many clinicians are paid by contract rather than salary. “If a client doesn’t come to a session, the therapist doesn’t get paid,” Beidas said.

On a positive note, the researchers found that regardless of finances, systems that foster what they call “proficient organizational cultures”—those that expect therapists to be responsive to clients’ needs, have up-to-date knowledge, and be competent via established and validated measures—were more likely to implement CBT and less likely to experience turnover than agencies lacking those features. In fact, organizational factors were more important than individual therapist factors in influencing successful practice change, the team found. Given these findings, “investing in organizations themselves seems like a really important [next] target,” Beidas said.

In an effort to boost innovations in implementation science that could lead to rapid breakthroughs in application, in 2018 NIMH began to fund the 11 ALACRITY centers across the country. Beidas and a number of Penn colleagues, including co-principal investigators David Mandell, ScD, and Alison Buttenheim, PhD, received one of these grants. The team has partnered with Penn’s Center for Health Incentives and Behavioral Economics to study how behavioral economics principles could boost their work in Philadelphia by helping to improve treatment adherence, increase clinician collection of data, and spark implementation innovations by crowd sourcing strategies from front-line clinicians, for example.

Another ALACRITY center is housed at the University of Washington. There, psychologist Patricia Areán, PhD, a professor in the Department of Psychiatry and Behavioral Sciences, and others are working to increase the use of evidence-based psychosocial treatments in underserved communities, including with rural mental health patients and Spanish-speaking migrant farmworkers.

A key element of their work is using a human design-centered approach called Discover, Design, Build, Test (DDBT). The protocol targets usability challenges—determining why it’s difficult to do evidence-based practices in a particular setting with particular providers—then applies an iterative design process to come up with solutions. The team is using this strategy in about a dozen ALACRITY incubator projects that it is undertaking.

One example is a project aimed at improving uptake of evidence-based practices among rural and Indigenous clients in Big Horn County, Montana, who have been diagnosed with depression and post-traumatic stress disorder (PTSD). When Areán’s team sat down with local clinic leaders to discuss challenges, two central problems emerged: a dearth of licensed mental health professionals to properly deliver treatment, and client attrition—clients who leave before they get full benefit from treatment.

After a few rounds of codesigned workshops, the research team, clinicians, and clinic leaders landed on a solution that could address both provider overload and client attrition and stay within budget: hiring a bachelor’s-level physician extender who could assume aspects of care. With provider supervision, the extender would regularly check in with patients and offer guidance and encouragement on their treatment plans. At points where the original provider’s expertise was needed—for example, when patients started talking about premature termination—the extender could tap them to intervene and get treatment back on track.

The researchers are launching a pilot project of this design with five teams at five clinics and will follow 10 patients per team to assess the impact on clinical care. If results are favorable, this change in service delivery could quickly be deployed on a larger scale and help address another long-standing problem in the field: mental health workforce shortages in rural areas. Because the extenders are often working toward advanced degrees at local universities, taking on such “gateway” roles could easily set them up for more demanding positions, Areán noted.

As with other implementation and dissemination efforts, Areán hopes to eventually gather enough data from these projects to better understand common themes, problems, and solutions. In turn, those data could serve as starting points for other providers or systems that want to adapt or create interventions. That said, one finding is that “some solutions seem to be fairly unique to each setting,” Areán added—so her team is also considering how to disseminate the DDBT model itself.

These projects are just a taste of what’s happening in the field of implementation science and translational research. Many other NIH institutes, as well as the Centers for Disease Control and Prevention, are supporting work in the area, too. For example, since 1999, the National Institute on Drug Abuse has continuously funded the Clinical Trials Network, which to date has supported some 117 research projects looking at innovative ways to improve uptake of evidence-based substance use treatments. There is even an institute devoted to translating research into practice, primarily in biomedicine: the National Center for Advancing Translational Sciences.

While the field has a long way to go to meet all implementation challenges, those doing this work say they wouldn’t want to do anything else.

“We’re a fairly young field, and so far, I can’t point to many projects where we can say that we’ve absolutely figured it out and we know exactly what to do,” said Beidas. “But the reason I get up in the morning, the reason I stay excited about this work, is the idea of eventually having impact at scale across populations.”