Adaptive School-based Implementation of CBT (ASIC): clustered-SMART for building an optimized adaptive implementation intervention to improve uptake of mental health interventions in schools

Abstract

BackgroundDepressive and anxiety disorders affect 20–30% of school-age youth, most of whom do not receive adequate services, contributing to poor developmental and academic outcomes. Evidence-based practices (EBPs) such as cognitive behavioral therapy (CBT) can improve outcomes, but numerous barriers limit access among affected youth. Many youth try to access mental health services in schools, but school professionals (SPs: counselors, psychologists, social workers) are rarely trained adequately in CBT methods. Further, SPs face organizational barriers to providing CBT, such as lack of administrative support. Three promising implementation strategies to address barriers to school-based CBT delivery include (1) Replicating Effective Programs (REP), which deploys customized CBT packaging, didactic training in CBT, and technical assistance; (2) coaching, which extends training via live supervision to improve SP competence in CBT delivery; and (3) facilitation, which employs an organizational expert who mentors SPs in strategic thinking to promote self-efficacy in garnering administrative support. REP is a relatively low-intensity/low-cost strategy, whereas coaching and facilitation require additional resources. However, not all schools will require all three strategies. The primary aim of this study is to compare the effectiveness of a school-level adaptive implementation intervention involving REP, coaching, and facilitation versus REP alone on the frequency of CBT delivered to students by SPs and student mental health outcomes. Secondary and exploratory aims examine cost-effectiveness, moderators, and mechanisms of implementation strategies.MethodsUsing a clustered, sequential multiple-assignment, randomized trial (SMART) design, ≥ 200 SPs from 100 schools across Michigan will be randomized initially to receive REP vs. REP+coaching. After 8 weeks, schools that do not meet a pre-specified implementation benchmark are re-randomized to continue with the initial strategy or to augment with facilitation.DiscussionEBPs need to be implemented successfully and efficiently in settings where individuals are most likely to seek care in order to gain large-scale impact on public health. Adaptive implementation interventions hold the promise of providing cost-effective implementation support. This is the first study to test an adaptive implementation of CBT for school-age youth, at a statewide level, delivered by school staff, taking an EBP to large populations with limited mental health care access.Trial registrationNCT03541317—Registered on 29 May 2018 on ClinicalTrials.gov PRSElectronic supplementary materialThe online version of this article (10.1186/s13012-018-0808-8) contains supplementary material, which is available to authorized users.

Designs and methods for implementation research: Advancing the mission of the CTSA program

“…The SMART design allows for building time-varying adaptive implementation strategies (or stepped-care strategies) based on the order in which components are presented and the additive and combined effects of multiple strategies [15]. Kilbourne et al assessed the effectiveness of an adaptive implementation intervention involving three implementation strategies (replicating effective programs [39], coaching, and facilitation) on cognitive behavioral therapy delivery among schools in a clustered SMART design [40]. In the first phase, eligible schools were randomized with equal probability to a single strategy vs. the same strategy combined with another implementation strategy.…”

Implementing integrated services in routine behavioral health care: primary outcomes from a cluster randomized controlled trial

“…However, if examining the impact of NIATx adherence or participation, much like the dose response effect with medications or psychosocial treatments, more differences between the groups were displayed. Future research might consider designs such as Sequential Multiple Assignment Randomized Trial, such as utilized by Kilbourne et al [47]. Measuring the impact of an initial discrete strategy (e.g.…”

The Balanced Opioid Initiative: Protocol for a clustered, sequential, multiple-assignment randomized trial to construct an adaptive implementation strategy to improve guideline-concordant opioid prescribing in primary care

“…The trial is an unrestricted, 2x2, clustered, sequential, multiple-assignment, randomized trial (SMART) [25][26][27] (see Figure 2). Because our goal is to test the effectiveness of the components of an implementation strategy while gathering clinical data related to patient outcomes, the study can be viewed as a hybrid type 3 effectiveness-implementation trial design [30].…”

“…This combination of a sequenced and tailored approach to systems consultation is known as an adaptive implementation strategy [25][26][27][28][29][30]. However, two sets of challenges prevent us from evaluating or recommending such an approach to addressing opioid prescribing in primary care using the results of our pilot alone.…”