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Strategies to Predict, Measure, and Improve Psychosocial Treatment Adherence
Abstract and Figures
Nonadherence to psychosocial and behavioral treatment is a significant public health problem that presents a barrier to recovery and effective treatment. An estimated 20% to 70% of individuals who initiate psychosocial mental health services discontinue treatment prior to clinicians' recommendations. Empirically supported, evidence-based, stand-alone or adjunctive psychosocial interventions treat an increasingly wide range of mental health conditions. A core assumption of most, if not all, interventions is that clients will fully and actively engage in the treatment protocol. Adherence to psychosocial treatment has received much less scientific attention, however, than adherence to medical treatment. Drawing extensively from existing research, this comprehensive review conceptualizes several types of psychosocial and behavioral treatment adherence, examines predictors of adherence to psychosocial treatment, summarizes measures of adherence, and describes existing interventions to enhance psychosocial treatment adherence.
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... Exception reporting occurs when providers track negative instances of some targeted behavior, like not attending one's therapy appointment or not taking one's prescribed medication. Rather than tracking each successful behavioral event (Gearing et al., 2011(Gearing et al., , 2014, the "exception" is noted when the intended behavior or event does not occur, thus decreasing provider burden. This approach is derived from the Total Quality Management concept of measuring defects/errors in order to reduce/eliminate them in which only instances where something goes wrong or something out of the ordinary occurs are recorded (Ahire et al., 1995;Black & Porter, 1996;Dean & Bowen, 1994;Hackman & Wageman, 1995;Powell, 1995;Roberts & Sergesketter, 1993); however, this approach has been implemented less often in evaluations to inform continual program improvement and quality assurance efforts within social service settings. ...
... Evaluating client outcomes is essential to evidence-based practice (Forman, 2015;Gant, 2017;Gearing et al., 2014). Ongoing thoughtful evaluation of client processes and outcomes provides valuable information that can inform subsequent clinical decision-making to improve client care and interventions. ...
Federally funded medical and behavioral healthcare programs often have substantial evaluation outcome tracking and reporting requirements, which can become burdensome to program staff resulting in decreased buy-in, increased chance of staff burnout and turnover, and less rigorous and consistent data collection efforts. To address this issue, a novel data collection approach, “exception reporting,” was implemented to supplement and support the required data collection for a federally funded Assertive Outpatient Treatment (AOT) program. This work details the process and outcomes related to exception reporting for this comprehensive behavioral health treatment program that serves justice involved clients with serious mental illness (SMI). Results indicate that exception reporting was easily integrated into clinician’s normal workflows and resulted in a number of benefits. Specifically, results indicated that exception reporting decreased the data collection burden for program staff while allowing them to efficiently track program outcomes required by the funder. Additional research into which practice settings exception reporting can most easily be integrated into, and which client outcomes may be best tracked using this methodology, is indicated.
... Conversely, a majority of individuals with mental disorders will not engage in formal services (Henderson et al., 2013). Further, an estimated 20% to 70% of individuals who initiate such psychosocial MH services discontinue treatment prior to clinicians' recommendations (Gearing et al., 2011(Gearing et al., , 2014. Similarly, not engaging in, poor patient-provider collaboration and nonadherence to medication protocols and treatment is the Achilles' heel of effective MH treatment. ...
... The majority of individuals with MH needs do not access or do not have access to effective MH treatment. MH interventions and services are likely to be ineffective with individuals who do not access treatment, drop out of treatment prematurely, or fail to engage with intervention protocols (Gearing et al., 2012(Gearing et al., , 2014. Despite annual investments of millions of dollars to develop and disseminate these interventions, nonengagement remains a significant threat to treatment effectiveness. ...
The Center for Mental Health Research and Innovation in Treatment Engagement and Service (MH-RITES Center) at the Graduate College of Social Work, University of Houston is an international multidisciplinary research center focused on improving treatment engagement and outcomes for those experiencing mental health concerns. Established in 2017, the mission of the MH-RITES Center is to drive empirically supported and evidence-based innovation that achieves optimal treatment access and engagement in mental health services by individuals and families who need them, specifically in historically marginalized communities. This article describes the history and guiding principles, organizational structure, funding sources, and physical resources of the MH-RITES Center while highlighting completed, ongoing, and future projects supporting the Center's mission.
... Community-driven approaches in mental health prevention and promotion demonstrate enabling factors that potentiate social support, empowerment processes, and healing among refugee communities [24]. Involving community stakeholders as active agents in intervention implementation process can also promote non-pre-registered or unexpected outcomes critical to improving social determinants of mental health, such as ownership, sustainability, and cultural appropriateness of the intervention, which are crucial to addressing social determinants of mental health [25,26]. ...
Refugee newcomers resettled in the United States face numerous challenges impacting their mental health and overall well-being. Despite extensive research on clinical interventions, multimodal interventions with peer-based group models in resettlement contexts remain scarce. Adopting a realist evaluation approach, this study aims to conduct a comprehensive implementation evaluation of a complex community-based mental health and psychosocial support (CB-MHPSS) group intervention, examining its mechanisms and processes while considering the interplay among context, implementing agents, and community settings. Qualitative and quantitative data on the implementation process were collected from 11 refugee agencies, involving trained resettlement staffers (n = 32) and refugee community facilitators (n = 31) who implemented the 31 CB-MHPSS psychosocial groups in 2021. The analysis included fidelity reports, process reflections, and follow-up survey responses, utilizing a structured template based on the CB-MHPSS Theory of Change (ToC) and Medical Research Council (MRC) guidance. Results of an in-depth exploration of complex relations between context and implementation processes reveal the vital role that adaptability to socio-ecological circumstances during the global coronavirus pandemic played in achieving successful implementation of psychosocial group interventions. Striking a balance between fidelity and refinement of intervention of the intervention curriculum emerged as crucial factors for aligning facilitation goals with newcomer needs. This approach maintained the integrity and appropriateness of the intervention, requiring implementers to utilize local knowledge of community resources and their understanding of lived experience of forced migrants and their within the community. Furthermore, exploring intervention barriers and facilitators revealed merits aligned with program change theories and areas for adjustment, while cataloged guidelines addressed community needs, showcasing competence beyond standard checkboxes. Strategic dissemination guidance provided by the central office in a supportive and nonintrusive manner facilitated uptake in a participatory and context-specific manner. This study emphasizes the importance of leveraging community partnerships and local knowledge to result in sustained improvements in the mental health and well-being of refugees.
... Access to mental health care is an international public health challenge and an important consideration when discussing help-seeking behaviors (5,6). Without treatment, mental health problems can have staggering implications for individuals and society, with consequences including unnecessary disability resulting in diminished quality of life, poverty, lost productivity, impact to the local economy, and increased healthcare costs (7). ...
Most people in need of mental health services in Mexico do not seek formal support or professional services to address their mental health needs. Understanding help-seeking behaviors is crucial to addressing underutilized mental health services and to leverage health promotion efforts. Data were collected as part of a larger research project on stigma and help-seeking for mental-health-related concerns in Mexico. A convenience sample of 469 adults residing in Mexico City participated in the study using an experimental vignette methodology assessing stigma toward individuals with mental health conditions, along with characteristics and demographic correlates of help-seeking. All survey measures were administered in Spanish. A structural regression was conducted for the outcome ‘openness to professional help seeking for mental health problems’ as a latent variable. Compared with males, females were more open to professional help seeking ( b = 0.09, p = 0.038), as were people who endorsed higher spirituality ( b = 0.01, p = 0.006); while people who experienced self-stigma were less open to professional help-seeking for mental health concerns ( b = −0.15, p = 0.005). Self-stigma was a major driver of low service utilization. Contrary to previous studies, spirituality was a significant positive predictor of professional help-seeking. A more nuanced understanding of mental health help-seeking in Mexico can be useful for outreach efforts to increase service utilization both in Mexico and among Latinos in the United States (US). Given historical, geographic, and cultural ties with the US, it is important to understand mental health help-seeking in Mexico, which may relate directly to help-seeking behaviors in many US Latinos who have immigrated to the US. Directions for future research and practice implications are discussed, including a roadmap for health promotion activities.
... Mental health research has consistently maintained that receiving appropriate treatment for mental illness promotes well-being, social and economic betterment, stable housing and employability, and overall better functioning (Dixon, Holoshitz, and Nossel 2016;Gearing et al. 2014). However, factors that influence treatment-seeking are varied and less understood. ...
The reported 20% prevalence rate of diagnosable mental illnesses in China might be underestimated due to individuals’ hesitation to report mental health problems. This study tested whether a person’s mental health diagnosis would lead to endorsement and preference for professional care. A community-based survey was conducted in Shanghai, China (n = 466). A structural model showed that 68.8% of the respondents endorsed professional help. Male respondents had a lower endorsement rate for individuals diagnosed with substance use compared to PTSD, suicide, or schizophrenia. Female respondents showed a higher endorsement rate on formal care for schizophrenia compared to PTSD or depression. In the models between health and mental health care, 34% of the respondents endorsed health care, whereas 46% of the respondents endorsed mental health care, with helping-seeking attitudes and age being significant covariates. In China, resources allocated to public education may improve acceptance of professional pathways to mental health care.
... Mental health research has consistently maintained that receiving appropriate treatment for mental illness promotes well-being, social and economic betterment, stable housing and employability, and overall better functioning (Dixon, Holoshitz, and Nossel 2016;Gearing et al. 2014). However, factors that influence treatment-seeking are varied and less understood. ...
The reported 20% prevalence rate of diagnosable mental illnesses in China might be underestimated due to individuals’ hesitation to report mental health problems. This study tested whether a person’s mental health diagnosis would lead to endorsement and preference for professional care. A community-based survey was conducted in Shanghai, China (n = 466). A structural model showed that 68.8% of the respondents endorsed professional help. Male respondents had a lower endorsement rate for individuals diagnosed with substance use compared to PTSD, suicide, or schizophrenia. Female respondents showed a higher endorsement rate on formal care for schizophrenia compared to PTSD or depression. In the models between health and mental health care, 34% of the respondents endorsed health care, whereas 46% of the respondents endorsed mental health care, with helping-seeking attitudes and age being significant covariates. In China, resources allocated to public education may improve acceptance of professional pathways to mental health care.
... Many of these interventions have shown promise and demonstrated higher levels of client acceptability and efficacy (Mendez & Cortina, 2021). However, if individuals needing mental health services do not seek formal treatment in the first place, the cultural acceptability and efficacy of these mental health services is rendered ineffective (Gearing et al., 2011(Gearing et al., , 2014. ...
Como la mayor población minoritaria de EE. UU. y también una de las de más rápido crecimiento, es crucial que las/os latinas/os accedan a una atención médica adecuada e integral, incluido el tratamiento de la salud mental. Las investigaciones actuales sugieren que las/os latinas/os tienen baja estima por los servicios de salud mental en general. En este estudio se exploran las preferencias de tratamiento y las vías de atención de las/os latinas/os cuando buscan ayuda para cuestiones relacionadas con la salud mental mediante el uso de datos de una encuesta comunitaria realizada a aproximadamente 500 personas adultas latinas sobre creencias y actitudes acerca de la salud mental y la búsqueda de ayuda. Los resultados revelaron que más de la mitad de las/os participantes prefieren buscar ayuda inicialmente por medio de fuentes informales de atención (p. ej., amigos, familiares, compañeros de trabajo, líderes religiosos, sanadores religiosos) en lugar de proveedores formales de servicios de salud mental (p. ej., profesionales de la salud formales, un hospital, una clínica). Las características demográficas de las personas encuestadas y los síntomas experimentados por la persona necesitada de ayuda predijeron las preferencias en las vías preferidas de búsqueda de ayuda. Se presentan las implicaciones para fortalecer el compromiso con el tratamiento de las/os latinas/os que presentan problemas de salud mental.
... Third, assessments in the present study included measures that were observer-rated, therapist-rated, and patient-rated. This may have introduced rater effects, particularly as some evidence suggests that health care providers may overestimate patient adherence (Gearing et al., 2014;World Health Organization, 2003). Thus, it is possible that variance across raters may have partially accounted for the findings. ...
Patient memory for treatment is poor. Memory support strategies can be integrated within evidence-based psychological treatments to improve patient memory for treatment, and thereby enhance patient outcomes. The present study evaluated possible mechanisms of these memory support strategies. Specifically, we tested whether therapist use of memory support strategies indirectly predicts improved patient outcomes via serial improvements in (a) patient adherence throughout treatment and (b) patient utilization and competency of treatment skills. Adults with major depressive disorder (N=178, mean age=37.93, 63% female, 17% Hispanic or Latino) were randomized to Cognitive Therapy plus a Memory Support Intervention or Cognitive Therapy-as-usual. Because therapists from both treatment groups used memory support strategies, data from conditions were combined. Blind assessments of depression severity and overall impairment were conducted before treatment, immediately post-treatment (POST), at six-month follow-up (6FU), and at 12-month follow-up (12FU). Patient adherence to treatment was rated by therapists and averaged across treatment sessions. Patients completed measures of treatment mechanisms – namely, utilization and competency in cognitive therapy skills – at POST, 6FU, and 12FU. Results of serial mediation models indicated that more therapist use of memory support predicted lower depression severity at POST, 6FU, and 12FU indirectly and sequentially through (a) increased patient adherence during treatment and (b) more utilization and competency of Cognitive Therapy skills at POST, 6FU, and 12FU. The same patterns were found for serial mediation models predicting lower overall impairment at POST, 6FU, and 12FU. Together, boosting memory for treatment may represent a promising means to enhance pantreatment mechanisms (i.e., adherence and treatment skills) as well as patient outcomes.
Objective:
To analyze the correlation of referral mechanism-warm handoff or electronic referral and attendance at behavioral health appointments in an outpatient pediatric primary care setting.
Methods:
A retrospective cohort study was conducted in an inner-city pediatric primary care clinic from January 2019 to December 2019. Adolescent patients who screened positive for depression or anxiety were referred to a Licensed Master Social Worker (LMSW) either via a warm handoff (WH group, n = 148) or an electronic referral (EF group, n = 180). The EF group was contacted by the LMSW via telephone to schedule an appointment. Multiple logistic regression was used to analyze the correlation of type of referral, age, gender, race/ethnicity, primary language, and time between referral and first contact with attendance at three appointments.
Results:
The WH group was more likely to engage with mental health services compared to the EF group (odds ratio = 3.301, 95% confidence interval = 1.850-5.902, p = .002) while age, gender, race/ethnicity, and primary language had no correlation. Within the EF group, those who were contacted by the LMSW within 3 days (1-3 days group) were more likely to attend appointments (odds ratio = 2.680, 95% confidence interval = 0.414-8.219, p = .040). There was no difference in attendance in the WH group and the 1-3 days group (p = .913) DISCUSSION: A warm handoff between primary care providers and behavioral health clinicians is significantly correlated with engagement with behavioral health services for adolescents who screen positive for depression or anxiety. Contact with the family within 3 days of referral is significantly correlated with engagement compared to a longer duration between referral and family contact.
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Symptom improvement from intake until 4 months later was assessed for 33 adult and 35 child psychotherapy drop-outs. Client ratings, therapist ratings, and symptom checklist changes were used as measures. Early drop-outs (one or two visits) were less well adjusted than late drop-outs (three or more visits) for both adults and children, though the difference was stronger for adults. Few differences were found between late drop-outs and completers. It was concluded that outcome researchers should use routinely the same procedures for assessing drop-outs' and completers' outcomes and that improvement of early and late drop-outs should be distinguished.
This study used a benchmarking strategy to evaluate the effectiveness of community psychotherapy for depressed youth relative to evidence-based treatment in clinical trials. Symptom trajectories of depressed youth treated in community mental health centers (CMHCs) were compared with trajectories of youth treated with cognitive-behavioral therapy (CBT) in clinical trials. Overall, outcomes of CMHC youth more closely resembled those of control condition youth than youth treated with CBT. Within the CMHC sample, ethnic minority status and low therapy dose were related to worse outcomes. However, when outcomes for Caucasian youth and youth receiving longer term services were examined, the CMHC sample still performed more poorly than youth treated with CBT. The findings support the value of developing, testing, and exporting effective therapies for depressed youth to community clinic settings.
Objective:
To evaluate the effect of appointment reminders sent as short message service (SMS) text messages to patients' mobile telephones on attendance at outpatient clinics.
Design:
Cohort study with historical control.
Setting:
Royal Children's Hospital, Melbourne, Victoria.
Patients:
Patients who gave a mobile telephone contact number and were scheduled to attend any of five outpatient clinics (dermatology, gastroenterology, general medicine, paediatric dentistry and plastic surgery) in September (trial group) or August (control group), 2004.
Main outcome measures:
Failure to attend (FTA) rate compared between the group sent a reminder and those who were not.
Results:
2151 patients were scheduled to attend a clinic in September; 1382 of these (64.2%) gave a mobile telephone contact number and were sent an SMS reminder (trial group). Corresponding numbers in the control group were 2276 scheduled to attend and 1482 (65.1%) who gave a mobile telephone number. The FTA rate for individual clinics was 12%-16% for the trial group, and 19%-39% for the control group. Overall FTA rate was significantly lower in the trial group than in the control group (14.2% v 23.4%; P < 0.001).
Conclusions:
The observed reduction in failure to attend rate was in line with that found using traditional reminder methods. The ease with which large numbers of messages can be customised and sent by SMS text messaging, along with its availability and comparatively low cost, suggest it may be a suitable means of improving patient attendance.
Objective: Psychosocial treatment compliance is essential for effective treatment outcomes. A psychometrically valid compliance scale is required for identifying possible obstacles causing treatment non-compliance and testing the effectiveness of compliance therapy. This study developed a scale to measure psychosocial treatment compliance of people with psychotic disorders and established its psychometric properties.
Method: An initial item pool was generated by literature review and contacts with psychiatric professionals. The content validity and cultural relevancy of this scale were examined by experienced researchers, mental health professionals and mental health consumers which resulted in the 17-item Psychosocial Treatment Compliance Scale (PTCS). Some 108 adults with a DSM-IV diagnosis of psychosis verified by certified psychiatrists were recruited from mental hospitals and social service settings in Hong Kong. Self-stigma, self-esteem, self-efficacy, insight and attitudes to medication of the participants were measured by relevant assessment instruments through interviews. Case therapists then filled in the PTCS and recorded their demographic data. SPSS version 11.0 was used for data analysis.
Results: Exploratory factor analysis revealed a two-factor solution (participation and attendance) accounting for 70.74% of the variance. Test–retest reliability and internal consistency were 0.90 and 0.96, respectively, for ‘participation’; and 0.86 and 0.87, respectively, for ‘attendance’. Its convergent validity was supported by the correlational relationships with measures on self-stigma, self-esteem, self-efficacy, insight and attitudes to medication.
Conclusion: PTCS is a reliable and valid scale which may be used to measure the compliance to psychosocial treatment of people with psychotic disorders.
Background Psychiatric clinics have high non-attendance rates and failure to attend may be a sign of deteriorating mental health.
Aims To investigate why psychiatric out-patients fail to attend, and the outcome of attenders and non-attenders.
Method Prospective cohort study of randomly selected attenders and non-attenders at general adult psychiatric out-patient clinics. Subjects were interviewed at recruitment and severity of mental disorder and degree of social adjustment were measured. Six and 12 months later their engagement with the clinic and any psychiatric admissions were ascertained.
Results Of the 365 patients included in the study, 30 were untraceable and 224 consented to participate. Follow-up patients were more psychiatrically unwell than new patients. For follow-up patients, non-attenders had lower social functioning and more severe mental disorder than those who attended. At 12-month follow-up patients who missed their appointment were more likely to have been admitted than those who attended.
Conclusions Those who miss psychiatric follow-up out-patient appointments are more unwell and more poorly socially functioning than those who attend. They have a greater chance of drop-out from clinic contact and subsequent admission.
Various factors could play a role in a patient's decision to leave treatment. This study asks whether patients who leave treatment before one year are different from those who stay beyond a year in open-ended psychoanalytic psychotherapy, using a variety of experiential measures. Our data indicate that the personality trait of “openness” assessed at intake, correlates with staying in therapy, and that relationship factors as assessed by the patients during therapy correlate with staying in therapy at the beginning, at the average point of dropping out (before one year – average 31 weeks), and at the end of the study. These results indicate that the failure to engage in the therapeutic relationship is a salient factor in the phenomena of leaving before one year. Significant reductions in physical symptoms and other positive trends toward improvement do not emerge until such therapeutic engagement has occurred. We conclude that the personality trait of “openness,” and the quality of the therapeutic relationship significantly influence who will stay in open-ended psychoanalytic psychotherapy and who will go. Those who stay in psychoanalytic psychotherapy beyond one year benefit more from the experience than those who leave. Copyright © 2012 John Wiley & Sons, Ltd.