BACKGROUND: Self-injurious thoughts and behaviors (SITBs) are increasing dramatically among children and adolescents. Crisis support is intended to provide immediate mental health care, risk mitigation, and intervention for those experiencing SITBs and acute mental health distress. Digital mental health interventions (DMHIs) have emerged as accessible and effective alternatives to in-person care; however, most do not provide crisis support or ongoing care for children and adolescents with SITBs.
OBJECTIVE: To inform the development of digital crisis support and mental health care for children and adolescents presenting with SITBs, this study aims to (1) characterize children and adolescents with SITBs who participate in a digital crisis response service, (2) compare anxiety and depressive symptoms of children and adolescents presenting with SITBs versus those without SITBs throughout care, and (3) suggest future steps for the implementation of digital crisis support and mental health care for children and adolescents presenting with SITBs.
METHODS: This retrospective study was conducted using data from children and adolescents (aged 1-17 y; N=2161) involved in a pediatric collaborative care DMHI. SITB prevalence was assessed during each live session. For children and adolescents who exhibited SITBs during live sessions, a rapid crisis support team provided evidence-based crisis support services. Assessments were completed approximately once a month to measure anxiety and depressive symptom severity. Demographics, mental health symptoms, and change in the mental health symptoms of children and adolescents presenting with SITBs (group with SITBs) were compared to those of children and adolescents with no SITBs (group without SITBs).
RESULTS: Compared to the group without SITBs (1977/2161, 91.49%), the group with SITBs (184/2161, 8.51%) was mostly made up of adolescents (107/184, 58.2%) and female children and adolescents (118/184, 64.1%). At baseline, compared to the group without SITBs, the group with SITBs had more severe anxiety and depressive symptoms. From before to after mental health care with the DMHI, the 2 groups did not differ in the rate of children and adolescents with anxiety symptom improvement (group with SITBs: 54/70, 77% vs group without SITBs: 367/440, 83.4%; χ21=1.2; P=.32) as well as depressive symptom improvement (group with SITBs: 58/72, 81% vs group without SITBs: 255/313, 81.5%; χ21=0; P=.99). The 2 groups also did not differ in the amount of change in symptom severity during care with the DMHI for anxiety (t80.20=1.37; P=.28) and depressive (t83.75=-0.08; P=.99) symptoms.
CONCLUSIONS: This study demonstrates that participation in a collaborative care DMHI is associated with improved mental health outcomes in children and adolescents experiencing SITBs. These results provide preliminary insights for the use of pediatric DMHIs in crisis support and mental health care for children and adolescents presenting with SITBs, thereby addressing the public health issue of acute mental health crisis in children and adolescents.

BACKGROUND: Physical activity engagement following a cancer diagnosis is positively associated with survival, reduced risk of disease recurrence, and reduced cancer-specific and all-cause mortality. However, rates of physical activity engagement are low among individuals diagnosed with and being treated for breast cancer or prostate cancer.
OBJECTIVE: The purpose of this study was to describe the systematic process of developing an e-cycling intervention aimed at increasing physical activity among individuals living with prostate cancer or breast cancer and outline the key components to be implemented.
METHODS: The Medical Research Council guidance for developing complex interventions and the Behaviour Change Wheel were used to guide intervention development. Information was gathered from the literature and through discussions with end users to understand factors influencing e-cycling. These factors were mapped onto the Theoretical Domains Framework to identify potential mechanisms of action. Behavior change techniques were selected from theory and evidence to develop intervention content. Interested parties, including cycling instructors, end users, and behavior change experts, reviewed and refined the intervention.
RESULTS: Anticipated barriers and facilitators to e-cycling engagement were mapped onto 11 of the 14 domains of the Theoretical Domains Framework. A total of 23 behavior change techniques were selected to target these domains over 4 one-to-one e-cycling sessions delivered by trained cycling instructors in the community. Cycling instructors were provided a 3-hour classroom training session on delivering the intervention and a 3-hour practical session with feedback. The outcome of this work is a theory and evidence-informed intervention aimed at promoting e-cycling behavior among individuals being treated for breast cancer or prostate cancer, which is currently being implemented and evaluated.
CONCLUSIONS: Transparent intervention development and reporting of content is important for comprehensively examining intervention implementation. The implementation of this intervention package is currently being evaluated in a pilot randomized controlled trial. If the intervention is found to be effective and the content and delivery are acceptable, this intervention will form a basis for the development of e-cycling interventions in other survivors of cancer.
BACKGROUND: ISRCTN Registry ISRCTN39112034 https://www.isrctn.com/ISRCTN39112034; and IRSCTN Registry ISRCTN42852156; https://www.isrctn.com/ISRCTN42852156.

BACKGROUND: Youth suicide is a pressing public health concern, and transitions in care after a suicidal crisis represent a period of elevated risk. Disruptions in continuity of care and emotional support occur frequently. \"Caring contacts\" validating messages post discharge have the potential to enhance connections with patients and have been shown to improve outcomes. More recently, positive outcomes have been noted using caring contact text messages (SMS and MMS), which hold promise for engaging patients in a pediatric setting, but there are few studies describing the large-scale implementation of such an approach.
OBJECTIVE: This study aims to describe the process of developing and implementing automated caring contacts within a quality improvement framework, using a standardized series of supportive texts and images, for adolescents discharged from high-acuity programs at a large midwestern pediatric hospital. We describe lessons learned, including challenges and factors contributing to success.
METHODS: We implemented the caring contacts intervention in 3 phases. Phase 1 entailed developing supportive statements and images designed to promote hope, inclusivity, and connection in order to create 2 sets of 8 text messages and corresponding images. Phase 2 included piloting caring contacts manually in the hospital\'s Psychiatric Crisis Department and Inpatient Psychiatry Unit and assessing the feasibility of implementation in other services, as well as developing workflows and addressing legal considerations. Phase 3 consisted of implementing an automated process to scale within 4 participating hospital services and integrating enrollment into the hospital\'s electronic medical records. Process outcome measures included staff compliance with approaching and enrolling eligible patients and results from an optional posttext survey completed by participants.
RESULTS: Compliance data are presented for 4062 adolescent patients eligible for caring contacts. Overall, 88.65% (3601/4062) of eligible patients were approached, of whom 52.43% (1888/3601) were enrolled. In total, 94.92% (1792/1888) of enrolled participants completed the program. Comparisons of the patients eligible, approached, enrolled, and completed are presented. Primary reasons for eligible patients declining include not having access to a mobile phone (686/1705, 40.23%) and caregivers preferring to discuss the intervention at a later time (754/1705, 44.22%). The majority of patients responding to the optional posttext survey reported that the texts made them feel moderately to very hopeful (219/264, 83%), supported (232/264, 87.9%), that peers would be helped by these texts (243/264, 92%), and that they would like to keep receiving texts given the option (227/264, 86%).
CONCLUSIONS: This study describes the successful implementation of automated postdischarge caring contacts texts to scale with an innovative use of images and demonstrates how a quality improvement methodology resulted in a more effective and efficient process. This paper also highlights the potential for technology to enhance care for at-risk youth and create more accessible, inclusive, and sustainable prevention strategies.

BACKGROUND: High prevalence of depression or anxiety with opioid use for chronic pain complicates co-management and may influence prescribing behaviors.
OBJECTIVE: Compare clinical effectiveness of electronic medical record clinical decision support (EMR-CDS) versus additional behavioral health (BH) care management for reducing rates of high-dose opioid prescriptions.
METHODS: Type 2 effectiveness-implementation hybrid stepped-wedge cluster randomized trial in 35 primary care clinics within a health system in LA, USA.
METHODS: Patients aged 18+ receiving chronic opioid therapy for non-cancer pain with depression or anxiety and matched controls.
METHODS: EMR-CDS included opioid risk mitigation procedures. BH care included cognitive behavioral therapy; depression or anxiety medication adjustments; and case management.
METHODS: Outcomes of interest included difference-in-difference (DID) estimate of changes in probability for prescribing high-dose morphine equivalent daily dose (MEDD ≥50 mg/day and MEDD ≥90), average MEDD, and rates of hospitalization, emergency department use, and opioid risk mitigation.
RESULTS: Most participants were female with 3+ pain syndromes. Data analysis included 632 patients. Absolute risk differences for MEDD≥50 and ≥90 decreased post-index compared to pre-index (DID of absolute risk difference [95%CI]: -0.036 [-0.089, 0.016] and -0.029 [-0.060, 0.002], respectively). However, these differences were not statistically significant. The average MEDD decreased at a higher rate for the BH group compared to EMR-CDS only (DID rate ratio [95%CI]: 0.85 [0.77, 0.93]). There were no changes in hospitalization and emergency department utilization. The BH group had higher probabilities of new specialty referrals and prescriptions for naloxone and antidepressants.
CONCLUSIONS: Incorporation of a multidisciplinary behavioral health care team into primary care did not decrease high-dose prescribing; however, it improved adherence to clinical guideline recommendations for managing chronic opioid therapy for non-cancer pain.
BACKGROUND: ClinicalTrials.gov ID NCT03889418.

BACKGROUND: Although there is increased demand for behavioral health services, there is limited national data on the workforce prescribing psychotropics and/or medications for opioid use disorder (MOUD), and many current estimates are based on self-reported data or clinician rosters.
OBJECTIVE: To describe trends in the workforce prescribing psychotropics (i.e., antidepressants, antipsychotics, antianxiety medications, mood stabilizers) and/or MOUD from 2017 to 2021.
METHODS: Cross-sectional analysis of 2017-2021 IQVIA Xponent retail prescription claims data.
METHODS: Clinicians who prescribed more than ten total prescriptions for psychotropics and/or MOUD in a calendar year.
METHODS: We analyzed the number of prescriptions and prescribers by year, month, drug type, specialty type, payor type, and clinician county rurality.
RESULTS: There was a 2.7% increase in the number of prescribers between 2017 and 2021, with the highest growth among psychiatric nurse practitioners (44.7%), nurse practitioners (25.5%), and physician assistants (6.5%). Primary care physicians (PCPs) and advanced practice clinicians (APCs) made up more than half of the workforce but prescribed 3.5 times fewer prescriptions on average compared to psychiatric and addiction medicine specialists. PCPs and APCs in rural areas wrote the most prescriptions collectively for psychotropics and MOUD per month.
CONCLUSIONS: Using prescription data, a proxy for being active in the workforce, goes beyond specialty designation to identify the full workforce prescribing psychotropics and MOUD, including the growing role of APCs and PCPs.

Behavioral health crisis care (BHCC) is a care delivery model for individuals experiencing acute distress related to a mental health or substance use disorder. We examined market factors associated with comprehensive BHCC availability using 2022 data on mental health treatment facilities (n = 9385) obtained from the Substance Abuse and Mental Health Services Administration. We aggregated facility-level data by county (n = 3142) and merged with county-level market factors. Logistic regression models were used to examine the adjusted associations between market factors and BHCC availability. We found that 468 (14.9%) counties had at least one mental health treatment facility offering comprehensive BHCC services. Specifically, counties with more mental health providers (Adjusted Odds Ratio = 2.26, Confidence Interval = 1.32-3.86) and metropolitan counties (AOR = 3.26, CI = 1.95-5.43) had higher odds of having a comprehensive BHCC facility. Our findings highlight the importance of developing the mental health workforce to increase BHCC availability and a need to address disparities in rural counties.

Objective This study aimed to explore mental and behavioral health support trends for children aged 3-17, analyzing treatment and counseling using United States data from the 2016-2020 National Survey of Children\'s Health (NSCH) database. Methods Employing a retrospective observational design, we systematically retrieved and analyzed NSCH Database data from 2016 to 2020. The focus was on understanding mental and behavioral health treatment percentages over time, specifically targeting demographic variations such as age groups, gender, race/ethnicity, and the federal poverty level percentage. Graphical representation utilized Excel, summarizing results based on aggregated data for distinct time intervals, highlighting the importance of mental and behavioral health support for children aged 3-17. Results The study identified significant temporal trends in mental and behavioral health treatment, revealing notable fluctuations across demographic and socio-economic variables. Of the 22,812 participants, 51.7% (CI: 50.2-53.1%, n=12,686) received treatment, exposing disparities. Gender differences were evident, with higher treatment rates in females (53.7%, CI: 51.6-55.9%, n=6,166) than males (50.1%, CI: 48.2-52.0%, n=6,520). Age-specific patterns indicated lower intervention rates in younger children (33.5%, CI: 28.6-38.8%, n=447, ages 3-5) compared to adolescents (58.1%, CI: 56.2-59.9%, n=8, 222 ages 12-17). Conclusion The conclusion highlights significant temporal fluctuations and pronounced demographic disparities. Findings underscore varying prevalence rates among age groups, genders, racial/ethnic backgrounds, and socio-economic status categories. This study provides valuable insights for policymakers, healthcare professionals, and researchers, informing targeted interventions to enhance mental and behavioral health support for United States children.

BACKGROUND: There has been a longstanding effort to integrate behavioral health and HIV care for people with comorbid HIV and behavioral health needs, including those with severe mental illness (SMI). As this population frequents both behavioral health and HIV care settings, they were likely to experience new obstacles to the quality and availability of care during the COVID-19 pandemic. This study aims to describe how clinics for HIV services or behavioral healthcare-as well as co-located sites providing both-sought to rapidly shift protocols to maintain a standard of patient care for people with comorbid HIV and SMI while adapting to the unprecedented circumstances of the pandemic.
METHODS: We interviewed HIV and behavioral healthcare providers, clinic leaders, and support service agencies that served clients impacted by both HIV and SMI. Seventeen key informants across three settings (HIV care settings, behavioral health care settings, and integrated or co-located care settings) were interviewed in 2022. Interviews focused on changes in clinical services, protocols, and care provision strategies during and at the onset of the COVID-19 pandemic. Interviews were transcribed and coded using thematic analysis.
RESULTS: Commonly endorsed themes included both positive and negative changes in care and care provision during the pandemic. Negative impacts of the pandemic included the loss of physical space, exacerbated mental health needs and disengagement in HIV care, patient barriers to telehealth and the digital divide, and increased healthcare workforce burnout. Positive changes included improved healthcare delivery and care engagement through telehealth, new opportunities to provide a wide range of social services, paradoxical increases in engagement in HIV care for certain patients, and broad institution of workforce wellness practices.
CONCLUSIONS: Though COVID-19 presented several complex barriers to care for providers serving patients with comorbid HIV and SMI, the increased flexibility afforded by telehealth and a greater focus on collaborative approaches to patient care may benefit this patient population in the future. Additionally, the focus on workforce wellness may serve to increase retention and avoid burnout among providers. The strategies and lessons learned through adapting to COVID-19 may be invaluable moving forward as healthcare systems respond to future pandemics.

BACKGROUND: Policymaking is quickly gaining focus in the field of implementation science as a potential opportunity for aligning cross-sector systems and introducing incentives to promote population health, including substance use disorders (SUD) and their prevention in adolescents. Policymakers are seen as holding the necessary levers for realigning service infrastructure to more rapidly and effectively address adolescent behavioral health across the continuum of need (prevention through crisis care, mental health, and SUD) and in multiple locations (schools, primary care, community settings). The difficulty of aligning policy intent, policy design, and successful policy implementation is a well-known challenge in the broader public policy and public administration literature that also affects local behavioral health policymaking. This study will examine a blended approach of coproduction and codesign (i.e., Policy Codesign), iteratively developed over multiple years to address problems in policy formation that often lead to poor implementation outcomes. The current study evaluates this scalable approach using reproducible measures to grow the knowledge base in this field of study.
METHODS: This is a single-arm, longitudinal, staggered implementation study to examine the acceptability and short-term impacts of Policy Codesign in resolving critical challenges in behavioral health policy formation. The aims are to (1) examine the acceptability, feasibility, and reach of Policy Codesign within two geographically distinct counties in Washington state, USA; (2) examine the impact of Policy Codesign on multisector policy development within these counties using social network analysis; and (3) assess the perceived replicability of Policy Codesign among leaders and other staff of policy-oriented state behavioral health intermediary organizations across the USA.
CONCLUSIONS: This study will assess the feasibility of a specific approach to collaborative policy development, Policy Codesign, in two diverse regions. Results will inform a subsequent multi-state study measuring the impact and effectiveness of this approach for achieving multi-sector and evidence informed policy development in adolescent SUD prevention and treatment.

BACKGROUND: Inadequate and inequitable access to quality behavioral health services and high costs within the mental health systems are long-standing problems. System-level (e.g., fee-for-service payment model, lack of a universal payor) and individual factors (e.g., lack of knowledge of existing resources) contribute to difficulties in accessing resources and services. Patients are underserved in County behavioral health systems in the United States. Orange County\'s (California) Behavioral Health System Transformation project sought to improve access by addressing two parts of their system: developing a template for value-based contracts that promote payor-agnostic care (Part 1); developing a digital platform to support resource navigation (Part 2). Our aim was to evaluate facilitators of and barriers to each of these system changes.
METHODS: We collected interview data from County or health care agency leaders, contracted partners, and community stakeholders. Themes were informed by the Consolidated Framework for Implementation Research.
RESULTS: Five themes were identified related to behavioral health system transformation, including 1) aligning goals and values, 2) addressing fit, 3) fostering engagement and partnership, 4) being aware of implementation contexts, and 5) promoting communication. A lack of fit into incentive structures and changing state guidelines and priorities were barriers to contract development. Involving diverse communities to inform design and content facilitated the process of developing digital tools.
CONCLUSIONS: The study highlights the multifaceted factors that help facilitate or hinder behavioral health system transformation, such as the need for addressing systematic and process behaviors, leveraging the knowledge of leadership and community stakeholders, fostering collaboration, and adapting to implementation contexts.