Implementing brief and low-intensity psychological interventions for children and young people with internalizing disorders: a rapid realist review

“Innovations that have a clear advantage in either effectiveness or cost-effectiveness are more easily adopted and implemented.(35) Staff issues were also reported across multiple studies.”

“Implementation strategies are defined as methods or techniques used to enhance the adoption, implementation and sustainability of a clinical programme or practice.(12) The implementation gap is a term describing the time lag between research evidence and its integration into clinical practice or the gap between curren…”

“Quality assessment of included articles was conducted using the Mixed Methods Appraisal Tool.22 This tool was appropriate to use as it allowed for simultaneous evaluation of different study designs.”

“Internalizing disorders, such as anxiety and depression, are the most common in this age range.(2) Left untreated, internalizing mental health disorders are related to poor health, social and academic outcomes, as well as higher levels of self-harm and drug abuse.”

“The implementation gap is a term describing the time lag between research evidence and its integration into clinical practice or the gap between current best evidence and evidencebased practice.(13) There remains an implementation gap for brief and low-intensity interventions in child and adolescent settings.”

“Rapid realist methodology was used to synthesize the research to better understand the mechanisms of the interventions in particular contexts and settings.(17) This methodology is useful for timesensitive and/or emerging issues, of interest to policy makers and applies a realist approach to knowledge synthesis.”

“Left untreated, internalizing mental health disorders are related to poor health, social and academic outcomes, as well as higher levels of self-harm and drug abuse.(3) Several cognitive-behavioural therapy treatments (CBT) for childhood internalizing disorders have been systematically evaluated and received empirical…”

“Shorter, less intensive psychological interventions and those that can be delivered by practitioners with less formal training have been proposed as treatment options to increase the capacity of mental health services and reduce the need for more intensive, longer term treatment in the future.(5) There is evidence tha…”

“This methodology is useful for timesensitive and/or emerging issues, of interest to policy makers and applies a realist approach to knowledge synthesis.(18) This review used the four components of NPT to guide data extraction and identify both helpful and obstructing factors, processes and methods for implementing bri…”

“It may not be possible to overcome some of the central problems with staff turnover in mental health services, such as lack of career and job development and fixedterm contracts.(37) However, there is suggestion that a ‘Train-the-Trainer’ model could be used to great benefit, ensuring staff on short-term job contracts…”

“Where interventions are delivered in schools, this can be a familiar setting which is convenient (less time away from routine for appointments) and a less ‘clinical’ environment, although both educational and clinical locations raise questions around room bookings and physical location restraints.(36)”

“These treatments exist, but most people do not receive them.(33) The aim of this paper was to systematically review factors affecting the implementation of such interventions.”

“There is ongoing discussion over the best ways to engage young people in psychological interventions to avoid discrimination and embarrassment and potential suggestion that interventions could educate on strategies to alleviate the risk and/or impact of stigma.(39) Key facilitators identified in this review were the a…”

“or less, often utilizing self-help or internet-based materials.(19) Group interventions may last for 6– 9 hours of therapist contact time, as per NICE guidelines.”

“Within the wider psychology literature, stigma is a known barrier to accessing mental health services.(32) There is ongoing discussion over the best ways to engage young people in psychological interventions to avoid discrimination and embarrassment and potential suggestion that interventions could educate on strategi…”

“Brief and low-intensity interventions Research suggests that clinically meaningful benefit from CBT can be observed in six-to-eight sessions, and that brief, and even single-session interventions, are effective in reducing depression and anxiety outcomes in children and adolescents.(8) Shorter duration interventions c…”

“Most papers highlighted economic barriers which is in line with previous research, identifying how the costs of implementing evidencebased interventions can drive decision-making by service providers.(34) Including information on financial implications, whether the cost-effectiveness of the intervention, or suggestion…”

“Organizational factors are often fixed and difficult to change, however, identifying barriers such as cost can help inform researchers at intervention development stage, ensuring that implementation is considered from the start.(40) Engaging wider teams and networks rather than reliance on individual members of staff…”

“However, there is suggestion that a ‘Train-the-Trainer’ model could be used to great benefit, ensuring staff on short-term job contracts are continually trained.(38) Within the wider psychology literature, stigma is a known barrier to accessing mental health services.”

“Stepped care interventions are therefore designed to maximize resources by providing lower intensity and less costly approaches as a first line treatment.(9) Although an evidence-base is building which demonstrates the benefit of brief interventions in other conditions, such as substance use disorders (See Sarkar et a…”

“Theme 4: Implementation strategy Having a clear implementation strategy was identified as a key facilitator.(28) Several papers explored the benefits of providing tailored materials,(31) readiness planning and pre-implementation activities.”

“The remaining studies were conducted in the UK,(29) Australia(30) and one paper explored the implementation of their intervention used across the world.(31) Studies presented findings for a range of different low-intensity psychological interventions, including those for children and young people with anxiety,(4,24,25…”

“The quantitative and mixed methods papers were of medium quality as it was not possible to deduct if the measures used were appropriate,(24,25,28,30) and the final two papers were unable to be quality assessed due to their study design.(4,31)”

“Several papers explored the benefits of providing tailored materials,(31) readiness planning and pre-implementation activities.(24) Studies that had spent time preparing for implementation generally reported better uptake and sustainment of their intervention.”

“Other studies explored ways to make the intervention more engaging to staff, such as using case study examples, outlining clear target symptoms and expectations for young people and using self-referral or opt-in models.(27,29,31)”

“Studies presented findings for a range of different low-intensity psychological interventions, including those for children and young people with anxiety,(4,24,25,28) depression, eating problems(31) and stress.(29,30) Table 1 displays the intervention characteristics and study summaries are available in Appendix 3.”

“Shorter duration interventions can be more readily and widely deployed, increasing access to treatment and reductions in therapist contact time can be less costly to health service providers.(7) These interventions can be utilized as part of a ‘stepped care approach’, using CBT with minimal therapist assistance as a f…”

“…2012; Wisman et al., 2019) and is more common in psychological research, for example, in the treatment of self-injurious behaviors (see Dobias et al., 2023 for a review), substance abuse (Center for Substance Abuse Treatment, 1999), and anxiety and depression (see Roach et al., 2023 for a review).”

“LI psychological interventions, abbreviated versions of evidenced-based therapies that can be delivered by workers with little to no formalized mental health training, are generally limited in terms of duration and frequency of contact (e.g., 6–10 distinct sessions) [50, 51].”

“It is achieved through short-term steps and aims to enable the patient to know and accept him-or herself as he or she regards and accepts others and builds social relationships with them (Roach et al., 2023).”

“This included recent systemic reviews on guided self-help and low-intensity CBT interventions (Bennett et al ., 2019; Roach et al ., 2023) and updated searches, treatments described in a recently published book on brief and low-intensity interventions for children and young people (Bennett et al .,…”

“With staffing being a key facilitator (and poor staffing presenting a key barrier) to implementing LICBT in routine care settings [30] these recommendations must be considered within the context of the changing healthcare landscape and a drive to innovate through utilisation of existing resources…”

“Recent evidence supports the feasibility and effectiveness of brief, low-intensity psychological interventions for adolescents, particularly in improving internalizing symptoms and fostering emotional self-regulation [48].”

“…although much has been made of the potential for schools to enhance access to mental health support, our study highlights barriers that have been identified in previous research related to having sufficient time and space to deliver interventions in educational settings (Roach et al ., 2023).”

“A recent rapid review found that an essential aspect of successful implementation is training (Roach et al., 2023).”

“A recent review on barriers to implementing brief psychological interventions for children reported a lack of flexibility and possibilities for individualization as an obstacle to implementation [47].”

“The contextual literature concerning internalizing difficulties in children and young people also supports careful consideration of psychosocial pathways [25–27,31, 32] The evidence base has several important limitations.”