Improving Depression Management in Primary Care

背景：退伍军人管理局的初级保健-精神卫生一体化(PC-MHI)植根于循证 协作护理模式，其中护理经理、心理健康专家和初级保健提供者联合 在初级保健中治疗抑郁症。虽然PC-MHI使专家能够支持初级药物治疗 如果没有足够的护理，及时和充分的心理治疗是不可能实现的。需要另类治疗方式。 意义/影响：抑郁症使人丧失能力，影响着五分之一的退伍军人。心理治疗更受 对退伍军人，但充满了多层次的障碍(例如，工作人员的可获得性、病人去诊所的路程、有限的诊所时间)。 在不增强现有PC-MHI模式的情况下，使初级保健患者能够更有效地获得 在心理治疗方面，老兵对抑郁症的治疗不太可能有所改善。 创新：这项CDA旨在缩小VA初级保健患者获得心理治疗的差距 采用PC-MHI协作护理模式改善计算机化认知能力的抑郁症 行为疗法(CCBT)。CCBT可以通过互联网全天候访问，并有效地治疗了 30多次试验。在适度的专家支持下，它并不逊色于面对面的心理治疗。PC-MHI 可以促进退伍军人接受cCBT，使用基于证据的协作护理模式提供以下服务- UP护理管理和心理健康专家支持，这是最有效的CCBT试验的特征。 具体目标：这个CDA将使我成为一名VA实施科学家，设计、测试、实施、 并传播有效的协作式护理模式改进，以在初级保健中治疗抑郁症。我的 具体目标是：(1)调整PC-MHI协作护理，以提高退伍军人初级保健中cCBT的接受度 抑郁症患者，基于多层次利益相关者的投入；(2)为了初步测试可行性， CCBT增强协同护理对退伍军人抑郁症状的可接受性和潜在影响 以及在一个初级保健诊所的相关结果，为更大的、多地点的混合效果做准备- 实施试验；以及(3)就将试验结果转化为设计方案达成专家共识 CCBT-增强型协作护理，在退伍军人事务部当地、区域和国家可行。 方法：在目标1中，我将使用定性方法，并从退伍军人、退伍军人管理局提供者和 国家专家和运营领导人的其他关键利益攸关方(CDA顾问组)，以适应PC-MHI 改善cCBT摄取的协作式护理模式。在目标2中，我将进行一项试点随机对照试验 (RCT)检查对抑郁、患者激活和健康的可行性、可接受性和潜在影响- 退伍军人初级保健抑郁症患者接受(1)cCBT增强治疗后的相关生活质量 弗吉尼亚州西洛杉矶的协作护理(n=32)或(2)常规护理(n=32)，从基线到2个月(后 干预)。这项试点将使我能够进行一次多站点混合I型有效性实施随机对照试验。 在目标3中，我将使用改进的Delphi方法领导一个虚拟专家小组，以检查关键障碍和 在cCBT增强的协作护理模式中的促进者，以缩小获得心理治疗的差距 患有抑郁症和其他疾病的退伍军人接受常规退伍军人初级保健，这将由现有的 文献和基于退伍军人事务部的试点数据。CDA的培训和指导将有助于我过渡到 通过填补实施科学(和定性)方面的明确培训空白，独立的退伍军人事务部HSR&D调查员 方法)、临床试验设计(用于抑郁症护理)和健康信息学。 下一步/实施：调整PC-MHI的协作护理模式以纳入CCBT可以改进 获得心理治疗，并让大约400,000名患有抑郁症的未经治疗的退伍军人参与进来 心理治疗，特别是OIF/OEF/OND退伍军人寻求方便的护理。CDA将提供 指导和培训，开始我作为实施科学家的职业生涯，领导协作护理模式 使用新技术进行改进，以解决退伍军人在初级保健中未得到满足的需求和偏好。

Background: VA’s Primary Care–Mental Health Integration (PC-MHI) is rooted in evidence-based collaborative care models, where care managers, mental health specialists, and primary care providers jointly treat depression in primary care. While PC-MHI enabled specialists to support medication treatment in primary care, timely and sufficient access to psychotherapy is unattainable. Alternative therapy modalities are needed. Significance/Impact: Depression is disabling and affects one in five Veterans. Psychotherapy is preferred by Veterans, but fraught with multilevel barriers (e.g., staff availability, patient travel to clinic, limited clinic hours). Without enhancing existing PC-MHI models to enable better primary care patient access to effective psychotherapies, Veteran engagement in depression treatment is unlikely to improve. Innovation: This CDA aims to close the gap in psychotherapy access for VA primary care patients with depression by adapting PC-MHI collaborative care models to improve uptake of computerized cognitive behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in more than 30 trials. With modest specialist support, it is non-inferior to face-to-face psychotherapy. PC-MHI can facilitate Veteran uptake of cCBT, using an evidence-based collaborative care model to provide the follow- up care management and mental health specialist back-up that characterizes the most effective cCBT trials. Specific Aims: This CDA will enable me to be a VA implementation scientist who designs, tests, implements, and disseminates effective collaborative care model improvements to treat depression in primary care. My Specific Aims are: (1) to adapt PC-MHI collaborative care to improve uptake of cCBT among VA primary care patients with depression, based on input from multilevel stakeholders; (2) to pilot test the feasibility, acceptability, and potential effects of cCBT-enhanced collaborative care on Veterans’ depression symptoms and related outcomes in one primary care clinic, in preparation for a larger, multi-site hybrid effectiveness- implementation trial; and (3) to establish expert consensus on the translation of pilot findings into a design for cCBT-enhanced collaborative care that is feasible locally, regionally and nationally in VA. Methodology: In Aim 1, I will use qualitative methods and elicit feedback from Veterans, VA providers, and other key stakeholders of national experts and operations leaders (CDA advisory group) to adapt the PC-MHI collaborative care model to improve cCBT uptake. In Aim 2, I will conduct a pilot randomized controlled trial (RCT) to examine feasibility, acceptability, and potential effects on depression, patient activation, and health- related quality of life in VA primary care patients with depression receiving either (1) cCBT-enhanced collaborative care (n=32) or (2) usual care (n=32) in West Los Angeles VA, from baseline to 2-months (post- intervention). This pilot will position me to conduct a multi-site hybrid type I effectiveness-implementation RCT. In Aim 3, I will conduct a virtual expert panel using modified Delphi methods to examine critical barriers and facilitators in the cCBT-enhanced collaborative care model for closing the gap in psychotherapy access for Veterans with depression and other illnesses in routine VA primary care, which will be informed by existing literature and VA-based pilot data. The CDA training and mentorship will facilitate my transition into an independent VA HSR&D investigator by filling explicit training gaps in implementation science (and qualitative methods), clinical trial design (for depression care), and health informatics. Next Steps/Implementation: Adapting PC-MHI’s collaborative care model to incorporate cCBT can improve access to psychotherapy and engage the ~400,000 untreated Veterans with depression who prefer psychotherapy, especially OIF/OEF/OND Veterans seeking care that is convenient. The CDA will provide mentorship and training to begin my career as an implementation scientist who leads collaborative care model improvements using novel technology to address unmet needs and preferences of Veterans in primary care.