Assisted Identification and Navigation of Early Mental Health Symptoms in Youth

Grant Details

Funder: NIMH

Grant Number: R01MH124652

Grant Period: 1/18/2021 – 11/30/2024

Narrative: About 55% of children with significant mental health difficulties receive treatment and up to 80% of children with sub-clinical symptoms receive no treatment. Treatments are often not initiated until issues are significantly impacting the child and family. This study aims to conduct a pragmatic randomized trial in two non-academic health care systems to test a mental health family navigator model to promote early access to, engagement in, and coordination of needed mental health services for children. The first task of the study will focus on the implementation of a predictive model to identify symptomatic children with no diagnosed mental health disorder(s) or treatments initiated. The tool identifies patients with documentation of mental health symptoms or complaints in the free text of a progress note from a recent primary care or urgent care visit. Using this predictive algorithm, we will conduct a pragmatic randomized trial comparing intervention and usual care arm patients enrolled from Kaiser Permanente (KP) Washington and KP Northern California. The trial will enroll 200 patients per arm (n=400). Children with (1) a new mental health diagnosis but no treatment initiated; (2) a new mental health medication ordered with no mental health diagnosis; and (3) symptoms identified by the predictive model with no new mental health diagnosis or treatment initiated will be recruited. The study intervention will offer 6 months of support to the family by a mental health navigator (social worker). The navigator will perform an initial needs and barriers assessment with the family around mental health services, conduct ongoing motivational interviewing around mental health care, provide up to 4 psychotherapy sessions (when appropriate) via clinic-to-home video visits, help the family find and schedule with appropriate mental health providers in the community, and reach out ad hoc if mental health appointments or medication refills are missed. The primary outcome is the percentage of youth initiating psychotherapy. The secondary outcome is the percentage of youth with at least 4 mental health visits. We hypothesize that the intervention arm will have higher rates of psychotherapy use compared to the control arm. We will also assess initiation of psychotropic medications. All primary analyses will follow an intent-to-treat approach. A waiver of consent will be obtained to include data for all individuals offered the intervention in the analysis, regardless of the amount of intervention (“dose” of navigation) received.

Lead Site: KPWA (PI Rob Penfold)

Participating Site: KPNC

Current Status:

Recruitment is active at both KPWA and KPNC. N = 44 as of 10/25/2022.

Summary of Findings:

Publications:

Using NLP to Increase Identification of Child Maltreatment in EHR

Grant Details

Funder: NIMH (MHRN III Feasibility Pilot Program)

Grant Number: U19MH121738

Project Period: 7/1/2020 – 6/30/2021

Narrative:

Background: Child maltreatment is a critical public health issue and health care systems play an important role in identifying and treating children who experience maltreatment. To date, few studies of child maltreatment have used data from large health systems to try and understand how these systems identify and manage youth who experience maltreatment. Preliminary analyses of the number of children identified as having experienced child maltreatment in the most recent MHRN quarterly descriptive analyses (2018) indicate that there is likely a significant under-reporting of child maltreatment in the MHRN health systems. Epidemiologic studies suggest that many more youth would have been identified with child maltreatment. One reason for this potential under reporting is that providers may not use the ICD codes to document child maltreatment consistently. Some maltreatment may be discussed in chart notes but not documented using ICD codes. Better identification of maltreatment could aid both research and practice within health care systems. Natural Language Processing may help to identify additional youth with maltreatment. If NLP identifies cases that are not documented through ICD codes, this could indicate the need for health system efforts to develop new ways of consistently document child maltreatment. NLP might also help to identify any groups (e.g., age, gender, race/ethnicity) that may be particularly likely to have insufficient documentation of child maltreatment. 

This work aligns with NIMH’s strategies to increase research and improve outcomes of mental health services in diverse and vulnerable populations, and to conduct research that helps health systems to base care decisions on the best possible data.   

Research Question: The overarching question is does NLP allow us to obtain estimates the number of children who experience maltreatment more comparable to national epidemiologic data? Does NLP of chart notes identify new cases of child maltreatment that are not already documented with ICD codes? What is the overlap between the two methods? Are there differences by age group or race-ethnicity? Does NLP allow us to differentiate between new/current maltreatment versus history of maltreatment?

Methods: We propose to use simple NLP queries at 1 MHRN site (e.g., terms such as physical abuse, maltreatment) to search chart notes and to compare the number of cases identified through NLP and compare those to cases identified through ICD codes. We will also conduct analyses to see if there is variation in identification by age group, gender, and race/ethnicity.  

Planned Product: We plan to write a paper documenting our findings. We also plan to write a grant related to child maltreatment using this data.

  • Lead Site: KPWA (PI Rob Penfold)
  • Participating Sites:
  • KPSC (Co-I Sonya Negriff)
  • KPNW (Co-I Frances Lynch)

Current Status

  • NLP pipeline created
  • Manual adjudication of NLP “hits” complete
  • Descriptive statistics complete

Summary of Findings

The prevalence of child maltreatment as measured by adjudicated occurrences of terms and phrases discovered by NLP is much higher than when measured via discrete data elements.

Publications

None yet

Pragmatic Trial of Stepped Care for Adolescent Suicide Prevention (Youth SPOT)

Grant Details

Funder: Patient-Centered Outcomes Research Institute (PCORI)

Contract Number: PLACER-2020C3-20902

Project Period: 12/01/2021 – 11/30/2027

Brief narrative:

Adolescent suicide is the second leading cause of death in teenagers. Preventing suicide in teens would keep them safe, allow them to get the mental health help that they need, and also protect families, friends, and communities from grief and loss. There are several programs that have been shown to work for preventing suicide, including an approach called dialectical behavior therapy (DBT). However, the studies done so far are so small that it is still unknown whether DBT works for all groups of teens—teens at medium risk versus those at very high risk, boys versus girls, younger versus older teens—or whether different approaches may work better for some groups. This is important information, because it would help teens and their families to make the best choices from several suicide prevention program options. Hospitals, clinics, doctors, and therapists also need information about what suicide prevention services work best and should be made more available. The goal of this study is to answer these questions.

The first aim, which will be completed in the first 18 months of the project, will be to plan the main study comparing two approaches to suicide prevention in collaboration with young people who have lived with suicidal behavior, their parents, doctors, and therapists. The second aim will be to compare how well these two approaches work to prevent suicide attempts in a group of 9,800 teens. The third aim is to see whether the two approaches lead to differences in the mental health care each teen receives—like being hospitalized, taking medications, seeing therapists, and so on—and to see which program works best for different groups, such as young men versus young women, or Hispanic teens and those who are not Hispanic, as well as what works best for teens who are at medium, medium-high, and high risk for suicide.

The first suicide prevention approach is called “stepped care,” and offers three levels of services to teens, depending on their level of risk. Medium-risk teens will be offered monthly phone check-ins; medium-high risk teens will also be offered a chance to work with a therapist to create and use safety plans that spell out how teens can keep themselves safe and what they will do if they feel suicidal. Teens at the highest level of risk will also be offered DBT group therapy for six months. The second suicide prevention approach is called Zero Suicide (ZS) care. This program is used by many healthcare clinics, hospitals, and therapy centers across the United States. It encourages therapists and doctors to ask about suicide frequently, and to make sure that teens who are at risk of suicide are connected to the best health care available, which might be regular therapy, medications, or a combination of the two.

To determine who to include in this study, the team will use a computer program to predict the chance that a teen will make a suicide attempt in the next six months. This program uses data collected by the healthcare system and is about 85 percent accurate. Teens who are at medium or high risk of suicide based on the computer program will be assigned by chance, like the flip of a coin, to one of two suicide prevention approaches. The team will use healthcare and government databases to see what happens for teens over 12 months so the team can compare rates of suicide attempts, self-harm, and healthcare use.

The goal is to help teens to be treated in a way that allows them the most personal freedom. The results from this study will help health insurers and clinics decide what kinds of suicide prevention care to offer and to cover. They will also help doctors and therapists decide what approaches to recommend to patients, and help individual teens and their families decide what kind of care to receive. The team will share its results with researchers, healthcare organizations, and national groups that advocate for youth suicide prevention to make sure that they will have the information they need to make choices about the best suicide prevention options for all types of teens.

  • Lead Sites:
    • KPNW (Clinical Coordinating Center, co-PI Greg Clarke)
    • KPGA (Data Coordinating Center, co-PI Courtney McCracken)
  • Participating Sites:
    • KPWA (site PI Rob Penfold)
    • HealthPartners (site PI Rebecca Rossom)
    • Georgia State University (site PI Ashli Owen-Smith)
    • UCLA (site PI Joan Asarnow)
    • California State Lutheran University (Site PI Jamie Bedics)

Awarded Budget (total cost): $21,324,820

Funding Announcement

Personnel Contact List

Human Subjects: YES

Current status

Pilot testing of outreach and intervention delivery will begin in October 2022.

Summary of findings

Publications

Evaluating Zero Suicide Care Improvement Programs in MHRN Health Systems

Grant Details

Title: An Evaluation of the National Zero Suicide Model Across Learning Healthcare Systems

Funder: NIMH

Grant Number: 1U01MH114087

Grant Period: 08/03/2017 – 05/31/2022

Narrative: Health systems at six participating sites have all committed to developing and implementing various components of a National Zero Suicide Model (NZSM), originally developed at the lead site for this study, Henry Ford Health System (HFHS).  Each health system will decide which components to implement at their respective site.  This study will develop metrics to measure fidelity and outcomes for the NZSM components implemented in each system using EHR and insurance claims data.  The project will then use these metrics to conduct fidelity and outcome evaluation of the various NZSM approaches in each system using an Interrupted Time Series Design.

Short-term project objectives:

We seek to accomplish three specific aims:

  1. Collaborate with health system leaders across sites to develop EHR metrics to measure specific quality improvement targets and care processes tailored to local NZSM implementation.
  2. Examine the fidelity of the specific NZSM care processes implemented in each system.
  3. Investigate suicide attempt and mortality outcomes within and across NZSM system models.

Long-term project objectives:

Learnings from this study will be immediately available on the Zero Suicide and MHRN websites, shared directly with SAMHSA and NIMH (thru the MHRN), and disseminated broadly to health systems via Zero Suicide Training Academies well before published data are available. As such, our goal is rapid dissemination and translation to practice, as opposed to the standard research-to-practice model – which the NIH and others estimate can take 17 years.

  • Lead Site:
    • Overall PI: HFHS Brian Ahmedani
  • Participating Sites/Subcontractors:
    • KPWA (site PI Greg Simon)
    • KPCO (site PI Jennifer Boggs)
    • KPNW (site PI Greg Clarke)
  • Funder Contacts
    • Science Officer: Susan Azrin
    • Program Official: Michael Freed
    • Grants Management Official: Julie Bergerud

Documents & Reports

Funding Announcement

Personnel Contact List

Publications

Manuscripts in process

ZS manuscript tracker: https://airtable.com/shr7wfbafq5c1rwTY

MHRN manuscript proposal form: https://airtable.com/shrD81CbLqaRrF8ga

Child and Adolescent Mental Health

Goals / Mission

Our mission is to provide high quality information to clinicians and health system administrators about how to improve mental health outcomes for children and adolescents.

Research Priorities

The Child & Adolescent Mental Health Group is working on a variety of high priority and high impact issues including: suicide risk prediction and prevention, improving services for children with autism spectrum disorders, and navigation programs to increase access and utilization of mental health care.

Contact:

Robert Penfold, PhD

Kaiser Permanente Washington Health Research Institute

1730 Minor Ave. Suite 1600

Seattle, WA 98101

Phone: 206-287-2232

Email: robert.b.penfold@kp.org

Maximizing Biospecimen Collection for Childhood Disorders

Project Name:
Maximizing Biospecimen Collection for Childhood Disorders
Principal Investigator:
Lisa Croen, PhD
Principal Investigator Contact Information:
lisa.a.croen@kp.org
Principal Investigator institution:
Kaiser Permanente Northern California, Oakland, CA
Funder
NIMH
Funding Period:
07/2015– 06/2018
Abstract:
Autism Spectrum Disorder (ASD) and Bipolar Disorder (BD) are the two most common severe mental disorders affecting children and adolescents.  Few evidence-based treatments exist for either condition.  Furthermore, response to treatment varies widely between individuals – and no evidence exists to match individual children with specific treatments.  Research to address these gaps – both to develop new treatments and to more effectively match individuals with treatments – will isolating on identifying biomarkers or endophenotypes that can accurately identify more homogeneous subgroups of patients and genetically related family members.  This next generation of research will require collecting biospecimens from large and representative samples of families affected by childhood mental disorders and linking those specimens to comprehensive and longitudinal health records. The main aim of this pilot is to identify the best ways to maximize biospecimen collection from children with mental health conditions.  We plan to meet this goal by leveraging and extending our work during the first cycle of MHRN funding on the feasibility of biospecimen collection from families of children with Autism Spectrum Disorder (ASD).  We will use a mixed methods approach to develop low-cost, tailored recruitment and consenting processes that specifically address concerns about participating in studies using biospecimens from children with mental health conditions and that are appropriate to large and diverse populations.  
Grant Number:
U19MH092201
Participating Sites:                                       Kaiser Permanente Northern California, Oakland, CA (Lead Site)Kaiser Permanente Georgia, Atlanta, GAKaiser Permanente Northwest, Portland, OR
Investigators:
Lisa Croen, PhD
Ashli Owen-Smith, PhD
Frances Lynch, PhD
Major Goals: Specific Aim 1: Using data from a feasibility study of biospecimen collection conducted during the first cycle of MHRN funding and health system electronic medical record (EMR) data, we will examine the demographic and clinical characteristics of children and their families predicting successful recruitment of families to participate in biospecimen collection. Specific Aim 2: Explore knowledge, attitudes and beliefs about biobanking and perceived facilitators and barriers to biobank participation among parents of children with mental health conditions from diverse backgrounds using ethnographic/qualitative methods (interviews, focus groups). Specific Aim 3: a) Develop tailored methods for recruiting and consenting children/adolescents with mental health conditions and their families into a biospecimen bank for future research) Develop a strategy for pilot testing those methods across different pediatric mental health conditions.  Focus on low-cost methods appropriate for large and diverse populations
Description of study sample:
Fifteen families who participated in the MHRN1 study at each of the three study sites, for a total of 45 ASD interviews and 15 families who have a child with a bipolar disorder diagnosis at KPNC, for a grand total of 60 families.
Current Status:
Aim 1: Completed data analysis.Aim 2: Data analysis was completed. Manuscript has been drafted and is expected to be submitted for publication in the Fall of 2019.
Study Registration:15 ASD families have been recruited at KPGA15 ASD families have been recruited at KPNW30 families (15 ASD and 15 Bipolar) families have been recruited at KPNC.
Publications:
Manuscript for Aim 2 to be submitted for publication in the Fall of 2019.
Resources:
N/A
Lessons Learned:
In spite of the profound caregiver burden experienced by many parents of children with serious mental health-related issues, participants in the present study were eager to participate in research, in general, and in biospecimen research, in particular, as long as the research process involved trust, clarity, and flexibility. Researchers working with these populations need to make it easy for families to participate – even if that is less convenient and more costly for them – and should prioritize the sharing of knowledge gained by the research with participants at the end of the study.
What’s next? Working on new manuscripts.

Safer Use of Antipsychotics in Youth (SUAY)

Project Name:
Safer Use of Antipsychotics in Youth (SUAY)
Principal Investigator:
Robert Penfold, PhD
Principal Investigator Contact Information:
Robert.B.Penfold@kp.org
Principal Investigator institution:
Kaiser Permanente Washington Health Research Institute
Funder
NIMH
Funding Period:
Base period: 04/25/16 – 12/24/16
Option period 1: 12/25/16-12/24/17
Option period 2: 12/25/17-06/24/2021
Abstract:
This study proposes to test a quality improvement research program. The project is inspired by the Partnership Access Line (PAL) and Second Opinion program operated for the Washington State Medicaid program. PAL was established to bring rapid child mental health consultation access into underserved areas of WA State. Under the program, a mandatory Second Opinion review protocol is triggered for new antipsychotics prescriptions when a set of pre-established criteria are met. SUAY is a step-wise research contract with 3 separately-funded phases: (1) planning and development, (2) feasibility pilot study at 2 sites, and (3) full-scale pragmatic effectiveness trial at 4 sites. The usual care arm is primarily observational only. The only change from standard usual care is a best practice alert reminding providers of Choosing Wisely® guidelines when prescribing antipsychotics for youth. The interventional arm consists of a more robust best practice alert informing prescribers that the case will be reviewed by a child and adolescent psychiatrist and offering a provider-to-provider consultation for the prescriber and behavioral health access support for the patient. Patients with an intervention arm prescriber will be offered 6 months of behavioral health navigation to support access and engagement with therapy in the health system and up to 9 sessions of brief telemental health (clinic-to-home) therapy to bridge wait times to access in-person therapy in the delivery system. Outcomes will be assessed at 6 months.
Contract Number:
HHSN271201600002C
Participating Sites:
Kaiser Permanente Washington (KPWA)
Seattle Children’s Hospital (SCH)
Kaiser Permanente Colorado (KPCO)
Henry Ford Health System (HFHS) (base period and option period 1)
Kaiser Permanente Northwest (KPNW) (option period 2)
Nationwide Children’s Hospital (NCH) / Partners for Kids (PFK)
University of Washington (UW)
Investigators:
Robert Penfold, PhD – Kaiser Permanente Washington Health Research Institute
Greg Simon, MD, MPH – Kaiser Permanente Washington Health Research Institute
James Ralston, MD, MPH – Kaiser Permanente Washington Health Research Institute
Clarissa Hsu, PhD – Kaiser Permanente Washington Health Research Institute
Rebecca Yates Coley, PhD – Kaiser Permanente Washington Health Research Institute
Tobias Dang, MD – Kaiser Permanente Washington Behavioral Health Services
Robert Hilt, MD – Seattle Children’s Hospital
Kathleen Myers, MD – Seattle Children’s Hospital
Kelly Kelleher, MD – Nationwide Children’s Hospital (NCH) /Partners for Kids (PFK)
Brian Ahmedani, PhD – Henry Ford Health System (base period and option period 1)
Arne Beck, PhD – Kaiser Permanente Colorado
Bobbi Jo Yarborough, PhD – Kaiser Permanente Northwest
Andrea Hartzler, PhD – University of Washington (base period and option period 1)
Paul Fishman, PhD – University of Washington
Major Goals:
Base period (8 months): Develop a treatment algorithm and step-by-step clinical workflow that aims to promote the safer use of antipsychotics in youth aged 3-17 years who do not have a psychotic disorder, mania, autism spectrum disorder, or intellectual disability.  Base period activities include convening a consensus panel of national experts to develop the treatment algorithm; interviewing youth, parents, and prescriber clinicians; conducting user-centered design sessions with prescribing clinicians and psychiatrists; and preparing for an option period 1 pilot study. Option period 1 (12 months): Conduct a pilot study to test the feasibility, acceptability, reproducibility and implementation of the intervention and workflow in two health systems (up to 20 patients per clinical site).  Kaiser Permanente Washington and Nationwide Children’s Hospital will participate in the pilot. Option period 2 (3 years, 6 months): Conduct a full-scale pragmatic effectiveness study comparing usual care to the interventional arm at four health systems (up to 800 patients enrolled across the 4 clinical sites). Kaiser Permanente Washington, Nationwide Children’s Hospital, Kaiser Permanente Northwest, and Kaiser Permanente Colorado will participate in the pragmatic trial.
Description of study sample:
Provider-subjects: The study will pre-randomize clinicians credentialed to prescribe medications in the health systems’ internal electronic medical record. Providers will be randomized to one of two arms: (1) usual care control and (2) intervention. Patient-subjects: Patients between the ages of 3 and 17 not ordered an outpatient antipsychotic in the health system during the prior 6 months and not suffering from a psychotic disorder, mania, autism spectrum disorder or intellectual disability. Patient subjects will be added to a study log when a randomized provider enters an antipsychotic medication order for them in Epic.
Current Status:
The pragmatic trial fielded at Kaiser Permanente Washington in March 2018, Kaiser Permanente Colorado in June 2018, and at Nationwide Children’s Hospital in July 2018. Henry Ford Health System was unable to field the protocol and the contract was modified to add Kaiser Permanente Northwest as a fourth recruitment site. Kaiser Permanente Northwest fielded the trial in May 2019. The end date of the contract may be extended to allow for a longer recruitment period given delays to fielding. The study had enrolled a total of 500 subjects as of July 1, 2019 (63% of the target 800 subjects).
Study Registration:
The trial is registered in ClinicalTrials.gov under record number NCT03448575.
Publications:
Hartzler A, Ralston J, Penfold R, Kelleher K, Hannan T. Designing safer use of antipsychotics in youth: A human centered approach. Accepted by Psychiatric Services for publication.Schoenfelder-Gonzalez E, Myers K, Thompson E, King D, Glass A, Penfold R. Developing Home-Based Telemental Health Services for Youth: Practices from the SUAY Study. Accepted by the Journal of Telemedicine and Telecare for publication.
Resources: Clinical guidelines developed by a national panel of experts for the safer prescribing of antipsychotic prescribing in youth. EPIC build package. Study protocol and manual of procedures.
What’s next?
Recruitment for the large pragmatic effectiveness study will continue into Spring 2020 and intervention delivery and follow-up through Fall 2020. Data and safety monitoring board reports will continue to be prepared and delivered three times per year.