Ian Moore Bennett

BACKGROUND While Problem Solving Treatment (PST) for depression is an effective psychotherapy in primary care settings, it is not widely used and clinician fidelity to key elements drops quickly following training. Human Centered Design (HCD) is an approach to understanding the needs of product users which can uncover obstacles through the lens of usability. OBJECTIVE We sought to identify usability challenges and implementation solutions for both clinicians who wished to deliver PST and their patients, create a solution using HCD methods, and pilot this solution. METHODS As part of the University of Washington ALACRITY Center (NIMH-P50MH115837), we applied the Discover, Design, Build, and Test (DDBT) human-centered design framework. Discover, Design, and Build stages included clinician and patient observations and interviews, and identification of themes and support needs for PST. PST-Aid was created as an internet-based app to overcome obstacles to PST. A Type III hybrid effectiveness/ implementation pilot trial of identified solutions was planned with emphasis on its possible implementation benefits. Randomization to training in PST versus the PST-Aid intervention was planned with a new set of providers other than those involved with HCD co-design activities. Usability was assessed through self-assessed survey. Time to clinician certification in PST, their ongoing fidelity to PST, and clinically significant improvement in patient depression severity (PHQ-9 scores) were the primary outcomes of interest. RESULTS A range of HCD methods and rapid prototyping cycles were carried out with co-design clinicians (9 undergoing PST training-as-usual and 10 experienced PST clinicians) and their patients (n = 4), which led to a web-based application that served to support and “scaffold” PST tasks as well as provide decision support for both providers and patients (PST Aid app). Usability was acceptable (SUS = 76), and utility was high based on qualitative assessments. In the Test phase, 11 clinical social workers were randomized to study conditions (7 PST Aid, 4 PST as Usual). All PST Aid clinicians were successfully certified as PST practitioners, while only 33% of PST as usual clinicians achieved certification. More clinicians used PST with their patients in the PST Aid group than those in PST as Usual throughout the study period (72% vs. 50%; p<0.05). More participants in the treatment arm (PST Aid; 67%) had scores that improved to below 10 on the PHQ-9 than participants receiving PST as Usual, but this did not reach statistical significance (Fisher's exact test, p = .07). CONCLUSIONS We found that a human centered design approach to technology-based "scaffolding" can support the adoption, reach, and sustained fidelity of an evidence-based clinical intervention. Involving clinicians and patients in the design process may enhance the use and adoption of support tools. This pilot lays the groundwork for a large randomized hybrid effectiveness/implementation trial. CLINICALTRIAL ClinicalTrials.gov NCT03516513; https://clinicaltrials.gov/study/NCT03516513

Background: Although substantial progress has been made in establishing evidence-based psychosocial clinical interventions and implementation strategies for mental health, translating research into practice—particularly in more accessible, community settings—has been slow. Objective: This protocol outlines the renewal of the National Institute of Mental Health–funded University of Washington Advanced Laboratories for Accelerating the Reach and Impact of Treatments for Youth and Adults with Mental Illness Center, which draws from human-centered design (HCD) and implementation science to improve clinical interventions and implementation strategies. The Center’s second round of funding (2023-2028) focuses on using the Discover, Design and Build, and Test (DDBT) framework to address 3 priority clinical intervention and implementation strategy mechanisms (ie, usability, engagement, and appropriateness), which we identified as challenges to implementation and scalability during the first iteration of the center. Local redesign teams work collaboratively and share decision-making to carry out DDBT. Methods: All 4 core studies received institutional review board approval by June 2024, and each pilot project will pursue institutional review board approval when awarded. We will provide research infrastructure to 1 large effectiveness study and 3 exploratory pilot studies as part of the center grant. At least 4 additional small pilot studies will be solicited and funded by the center. All studies will explore the use of DDBT for clinical interventions and implementation strategies to identify modification targets to improve usability, engagement, and appropriateness in accessible nonspecialty settings (Discover phase); develop redesign solutions with local teams to address modification targets (Design and Build phase); and determine if redesign improves usability, engagement, and appropriateness (Test phase), as well as implementation outcomes. Center staff will collaborate with local redesign teams to develop and test clinical interventions and implementation strategies for community settings. We will collaborate with teams to use methods and centerwide measures that facilitate cross-project analysis of the effects of DDBT-driven redesign on outcomes of interest. Results: As of January 2025, three of the 4 core studies are underway. We will generate additional evidence on the robustness of DDBT and whether combining HCD and implementation science is an asset for improving clinical interventions and implementation strategies. Conclusions: During the first round of the center, we established that DDBT is a useful approach to systematically identify and address chronic challenges of implementing clinical interventions and implementation strategies. In this subsequent grant, we expect to increase evidence of DDBT’s impact on clinical interventions and implementation strategies by expanding a list of common challenges that could benefit from modification, a list of exemplary solutions to address these challenges, and guidance on using the DDBT framework. These resources will contribute to broader discourse on how to enhance implementation of clinical interventions and implementation strategies that integrate HCD and implementation science. International Registered Report Identifier (IRRID): PRR1-10.2196/65446

Background Although costs are of key importance to clinic leadership when considering adoption of new programs, few studies examine real-world resource needs associated with implementing complex interventions for chronic conditions in primary care. This analysis sought to identify the costs necessary to implement the evidence-based collaborative care model (CoCM), an integrated behavioral health program for common mental disorders in primary care. Methods Ten federally qualified health centers (FQHCs) adopted CoCM as part of a larger national randomized trial evaluating implementation strategies for CoCM when adapted for perinatal mental health. The Cost of Implementing New Strategies (COINS) tool was used to assess implementation costs associated with activities completed by sites as they progressed through the implementation process. National wage norms were used to calculate cost estimates for staff time. Results On average, clinics spent $40,778 (SD=$30,611) on implementation, with clinics ranging widely from $4,502 to $103,156. Three out of 10 participating clinics achieved competency in the intervention during the 2-year implementation period. Costs among competent clinics ranged from $20,944 to $65,415 (mean=$41,788). Clinics that did not achieve competency were more varied, with both the lowest and highest resource use. Significant staff effort was required to complete all implementation stages; clinical staff and program champions showed greatest effort. Conclusions Site implementation costs for this complex behavioral health intervention were substantial and varied dramatically, particularly among sites who did not achieve competence. Additional work is needed to identify optimal site resource investment related to implementation success for CoCM. Trial registration: ClinicalTrials.gov.NCT02976025. Registered on November 23, 2016.

Studies indicate a high burden of mental health disorders among female sex workers (FSWs) in low- and middle-income countries (LMICs). Despite available data on suicidal ideation and suicide attempts among FSWs, little is known about suicide deaths in this hard-to-reach population. This study aims to examine the extent to which suicide is a cause of maternal mortality among FSWs, the contexts in which suicides occur, and the methods used. From January to October 2019, the Community Knowledge Approach method for identifying cause-specific deaths in communities was employed across eight LMICs (Angola, Brazil, the Democratic Republic of the Congo (DRC), India, Indonesia, Kenya, Nigeria, and South Africa). A total of one thousand two hundred eighty FSWs provided detailed reports on two thousand one hundred twelve FSW deaths in the preceding 5 years, including 288 (13.6%) suicides, 178 (61.8%) of which were maternal. Of these maternal suicides, 57.9% occurred during pregnancy (antepartum), 20.2% within two months of delivery (puerperium), and 21.9% in the 2–12 months following delivery (postpartum). The highest proportion of suicides occurred in Nigeria, Kenya, and DRC in sub-Saharan Africa. A total of 504 children lost their mothers to suicide. Further research is needed to identify interventions for suicide risk among FSW mothers.

Physician-scientists are an essential part of the medical research enterprise, but are underrepresented in the specialty of Family Medicine. The capacity to build an evidence base informed by the needs of a particular specialty is an essential role of researchers in academic departments at schools of medicine. When the number of primary care researchers is limited, research on critical health care issues specific to primary care will also be limited. Well-established pathways for the successful cultivation of physician researchers include the identification and recruitment of aspiring researchers at the college and medical school levels. Major investments in their training are needed to support them over significant periods of time, including through research-oriented residency tracks, focused fellowships, and rigorous mentored career development awards lasting well into the first decade of a postresidency career. Successful models for pieces of this pathway are present in some departments of family medicine but should be enhanced in a systematic manner, and need to be established in a much greater number of departments. Disseminating this model of the physician-scientist pathway across academic departments will be necessary to significantly expand the number of successful family medicine physician-scientists.

Background: Organizational factors may help explain variation in the effectiveness of evidence-based clinical innovations through implementation and sustainment. This study tested the relationship between organizational culture and climate and variation in clinical outcomes of the Collaborative Care Model (CoCM) for treatment of maternal depression implemented in community health centers. Method: Organizational cultures and climates of 10 community health centers providing CoCM for depression among low-income women pregnant or parenting were assessed using the organizational social context (OSC) measure. Three-level hierarchical linear models tested whether variation in culture and climate predicted variation in improvement in depression symptoms from baseline to 6.5-month post-baseline for N = 468 women with care ±1 year of OSC assessment. Depression symptomology was measured using the Patient Health Questionnaire (PHQ-9). Results: After controlling for patient characteristics, case mix, center size, and implementation support, patients served by centers with more proficient cultures improved significantly more from baseline to 6.5-month post-baseline than patients in centers with less proficient cultures (mean improvement = 5.08 vs. 0.14, respectively, p = .020), resulting in a large adjusted effect size of d_adj = 0.78. A similar effect was observed for patients served by centers with more functional climates (mean improvement = 5.25 vs. 1.12, p < .044, d_adj = 0.65). Growth models indicated that patients from all centers recovered on average after 4 months of care. However, those with more proficient cultures remained stabilized whereas patients served by centers with less proficient cultures deteriorated by 6.5-month post-baseline. A similar pattern was observed for functional climate. Conclusions: Variation in clinical outcomes for women from historically underserved populations receiving Collaborative Care for maternal depression was associated with the organizational cultures and climates of community health centers. Implementation strategies targeting culture and climate may improve the implementation and effectiveness of integrated behavioral health care for depression.

Context: Adult depression treatment in primary care is improved by integrated behavioral health such as the Collaborative Care Model (CoCM) but outcomes vary across health centers. Objective: Identify CoCM team factors associated with variation in clinical outcomes. Study Design: Correlative study of survey with linked clinical data from routine care. Setting or Dataset: Primary care health centers in Washington state participating in two CoCM implementation and sustainment initiatives (MHIP and BHIP). Clinical data from the Care Management Tracking System (CMTS) used as part of routine clinical care in all sites. Population studied: CoCM clinical teams and adults diagnosed with depression and receiving care from 31 distinct clinic sites throughout Washington state. Instrument: A survey for CoCM Care Managers was developed based on qualitative work exploring CoCM team function in eight domains: overall team function (OTF), psychiatric consultant (PsyC), relationship with primary care physicians (RPCP), role in the practice (RP), training experience (TE), thoughts on CoCM (TOC), leadership support (LS), and overall experience with CoCM (EXP). Outcome Measures: Depression symptoms (PHQ-9) measured as part of regular clinical care. Clinically significant improvements were defined as ≥50% improvement, last PHQ-9 measured Results: Data from 59 Care Manager surveys and 2509 patients from 31 clinics showed psychometric evidence for the 8 survey domains. Unadjusted multilevel mixed-effects logistic regression found the PsyC domain was associated (p50% change in PHQ-9 (OR=1.32, p=0.046), last PHQ-9 Conclusions: An instrument to assess perceived functioning of the CoCM team had psychometric support. Perceived characteristics of psychiatric consultants was associated with likelihood of depression remission. Characteristics included interest in teaching, commitment to the site, making efforts to have weekly meetings, and willingness to assist care managers on adjustment of treatment strategies. This study is the first to quantify variation in CoCM team functioning with patient outcomes and can be used to inform training and the use of the CoCM.

Introduction: Mental, neurological and substance use conditions lead to tremendous suffering, yet globally access to effective care is limited. In line with the 13^th General Programme of Work (GPW 13), in 2019 the World Health Organization (WHO) launched the WHO Special Initiative for Mental Health: Universal Health Coverage for Mental Health to advance mental health policies, advocacy, and human rights and to scale up access to quality and affordable care for people living with mental health conditions. Six countries were selected as ‘early-adopter’ countries for the WHO Special Initiative for Mental Health in the initial phase. Our objective was to rapidly and comprehensively assess the strength of mental health systems in each country with the goal of informing national priority-setting at the outset of the Initiative. Methods: We used a modified version of the Program for Improving Mental Health Care (PRIME) situational analysis tool. We used a participatory process to document national demographic and population health characteristics; environmental, sociopolitical, and health-related threats; the status of mental health policies and plans; the prevalence of mental disorders and treatment coverage; and the availability of resources for mental health. Results: Each country had distinct needs, though several common themes emerged. Most were dealing with crises with serious implications for population mental health. None had sufficient mental health services to meet their needs. All aimed to decentralize and deinstitutionalize mental health services, to integrate mental health care into primary health care, and to devote more financial and human resources to mental health systems. All cited insufficient and inequitably distributed specialist human resources for mental health as a major impediment. Conclusions: This rapid assessment facilitated priority-setting for mental health system strengthening by national stakeholders. Next steps include convening design workshops in each country and initiating monitoring and evaluation procedures.