Remotely-Delivered Programs Targeting COVID-19 Stress-Related Depression and Substance Use

项目概要/摘要：针对COVID-19压力相关抑郁症和药物使用的远程交付计划COVID-19大流行带来了前所未有的日常压力水平，并可能增加抑郁症和药物使用率，可能会压倒行为健康治疗能力。我们已经制定了一个新的计划（CHA MindWell; CHA-MW），以解决我们的安全网卫生系统的卫生系统的多样化和社会经济弱势群体对行为健康服务的预期需求激增。它既有筛查/监测/转诊，也有早期干预的组成部分：首先，我们实施了远程计算机化适应性测试（CAT-MH ®），将有压力相关精神疾病风险的患者分为3级：轻微症状或低风险（第1层），轻度至中度症状或有风险但不符合现场治疗标准（第2层），和需要治疗的中度至重度症状（第3层）。在标准的CHA-MW中，CAT-MH每月通过电子邮件在线发送给参与者，以确定他们是否属于第3层，是否需要转介心理健康治疗。第二，第二层患者被转介到一个实时的在线心理教育计划-基于正念的认知治疗恢复力（MBCT-R），这是一个8周的小组改编自MBCT，这是有效的治疗压力，焦虑和抑郁（已知的危险因素使用物质），并防止复发性抑郁症患者复发。因此，MBCT-R将在COVID-19期间和之后产生影响。当参与者注册MBCT-R时，他们接收增强的CHA-MW（即，除了每月的CAT-MH监测外，每周进行一次监测），使我们能够密切确定是否需要更高水平的护理。我们将对有轻度至中度抑郁症状的2级患者进行随机分组（CAT抑郁量表50-75，PHQ-9等效性10-20），比较MBCT-R +增强的CHA-MW每周监测与以下任一项的3组比较有效性RCT：a）仅加强CHA-MW每周监测（如果需要，快速转诊到心理健康治疗），或B）异步互联网CBT（iCBT）应用+ CHA-MW每周监测。我们期望MBCT-R能减少抑郁症状（主要结果），压力，并间接防止物质使用（次要结果）。对于RCT中的一项子研究，我们将使用每日日记收集初步数据，以测量压力相关的情感反应性数据（压力日期间负面影响的上升和/或积极影响的减少），并在干预前后的2个高压力日和2个低压力日远程自适应地采集唾液炎性细胞因子（IL-6、TNF-a、IL-1b）。由于这种基于在线正念的实时干预与自然主义远程监控的实用有效性试验已经嵌入我们的安全网卫生系统，如果能有效减少抑郁症状，它可以立即实施并迅速传播，并可能在COVID-19期间和之后以及未来的公共卫生危机中影响全国的行为卫生系统。

Project Summary/Abstract: Remotely Delivered Programs Targeting COVID-19 Stress-Related Depression and Substance Use The COVID-19 pandemic presents an unparalleled level of everyday stress and is likely to increase rates of depression and substance use, potentially overwhelming behavioral health treatment capacity. We have developed a new program (CHA MindWell; CHA-MW) to address the anticipated surge in demand for behavioral health services for our safety-net health system’s health system’s diverse and socioeconomically disadvantaged population. It has both a screening/monitoring/referral and an early intervention component: First, we implemented remote computerized adaptive testing (CAT-MH®) to stratify patients at risk of stress- related mental illness into 3 tiers: Minimal symptoms or low-risk (Tier 1), mild-to-moderate symptoms or at-risk but not meeting criteria for in-person treatment (Tier 2), and moderate-to-severe symptoms requiring treatment (Tier 3). In standard CHA-MW, CAT-MH is delivered online by email to participants monthly to determine if they are Tier 3 and referral to mental health treatment is needed. Second, Tier 2 patients are referred to a live, online psychoeducational program - Mindfulness-Based Cognitive Therapy for Resilience (MBCT-R), which is an 8-week group adapted from MBCT, which is effective for treatment of stress, anxiety, and depression (known risk factors for substance use), and preventing relapse among patients with recurrent depression. MBCT-R will therefore have impact both during and after COVID-19. When participants enroll in MBCT-R they receive enhanced CHA-MW (i.e., weekly in addition to monthly CAT-MH monitoring), allowing us to closely determine if a higher level of care becomes necessary. We will randomize Tier 2 patients who have mild-to- moderate symptoms of depression (CAT-Depression Inventory 50-75, PHQ-9 equivalency 10-20) in a 3-arm comparative effectiveness RCT to compare MBCT-R + enhanced CHA-MW weekly monitoring to either: a) enhanced CHA-MW weekly monitoring alone (with rapid referral to mental health treatment if needed), or b) an asynchronous internet CBT (iCBT) application + CHA-MW weekly monitoring. We expect MBCT-R to reduce depression symptoms (primary outcome), stress, and indirectly prevent substance use (secondary outcome). For a sub-study within the RCT, we will collect preliminary data using daily diaries to measure stress-related affective reactivity data (upticks in negative affect and/or reductions in positive affect during stress days) and adaptively sample salivary inflammatory cytokines (IL-6, TNF-a, IL-1b) remotely on 2 high and 2 low stress days before and after the interventions. Because this pragmatic effectiveness trial of a live, online mindfulness- based intervention with naturalistic remote monitoring is already embedded in our safety-net health system, it can be implemented immediately and disseminated rapidly if effective at reducing depression symptoms, and could impact behavioral health systems nationally during and after COVID-19 and future public health crises.