From Training to Practice: Understanding the Integration of Evidence-Based Psychotherapies for Depression (INTEGRATE)

背景抑郁症是一种非常普遍的心理健康障碍，它带来了沉重的疾病负担， 是退伍军人自杀的第二大危险因素。VA传播了三种有效的心理疗法 但治疗师使用这些治疗的比例<12%。令人惊讶的是，没有研究表明 研究了在VA中提供基于证据的抑郁症心理治疗（D-EBP）及其原因 潜在的不频繁交付，留下了一个关键的差距，抑郁症护理交付在VA。系统因素是A EBP使用的已知驱动因素，以及OMHSP努力的早期迹象和与抑郁症如何相关的独特因素， 护理组织在VA值得实证调查。意义D-EBP利用率低和 由于若干原因，缺乏关于障碍的经验证据是一个重大问题。首先，预防自杀是一个 在退伍军人事务部和全国范围内，抑郁症是自杀的主要危险因素。第二、 没有数据，就无法最大限度地提高针对提供者一级障碍的现有干预措施的效力 关于系统障碍。扩大其他EBP的覆盖范围（例如，创伤后应激障碍）需要在各个层面进行干预 （患者、提供者和系统），并且对于D-EBP也是如此。识别和瞄准系统 因素和探索治疗师因素，并进行第一次探索病人的看法D-EBPs将 支持这些早期的以提供者为重点的干预措施。此外，这项建议是及时的，因为它是在 OMHSP从评估培训期间D-EBP交付的预期障碍转变为开发 伙伴关系，以了解在实地遇到的障碍。最后，由于该提案正在审查D-EBP 在治疗其他精神健康状况的专业精神健康诊所分娩， EBP对这些其他条件的影响。创新/影响。拟议的3.5年研究将是 第一项研究探讨了VA治疗师对抑郁EBP利用率低的原因。我们的混合方法 方法将产生一个强大的理解，如何在专业精神的政策，资源和文化 健康诊所有助于治疗师使用低D-EBP。我们的目标与OMHSP的目标直接一致， 在退伍军人事务部精神卫生诊所增加临床实践指南一致性护理的实施。我们 根据与D-EBP相关的系统级因素对所有VA医疗中心进行拟议分类 交付、战略定性分析、干预规划和利益攸关方参与提供了宝贵的 将数据快速传输到OMHSP和现场。目标。1)定量研究卫生系统之间的关联 2）Qualitiment检验情境和系统因素对治疗师的影响 围绕提供D-EBP的决定; 3）制定干预目标和潜力的框架 减少D-EBP使用障碍的解决方案; 4）次要/探索性目标：a）Qualification探索如何 治疗师因素影响D-EBP的使用; B）探索患者对D-EBP的感知。方法论使用 解释性顺序混合方法设计，在目标1（定量）中，我们将抽象系统级和EBP FY21 Q3-FY22 Q2的训练数据。系统级因素和一般线性混合的描述性统计 模型分析将用于描述设施的特征，并检查系统因素之间的关联， 治疗师使用D-EBP。这将使我们能够快速了解D-EBP利用率的主要相关因素 以及这些因素在不同地点的变化，为我们的OMHSP合作伙伴提供关键数据，并为选择 目标2的网站。目标2和次要目标（定性）将包括与接受过以下培训的治疗师的访谈： 来自10个VA医疗中心的3名D-EBP和心理健康领导者（5名高绩效者和5名低绩效者; N = 120- 150)和20名患者了解他们对D-EBPs的看法。目标3将涉及干预规划， 德尔菲战略，以制定一个框架，减少系统障碍，以D-EBP交付。实施. 从我们的干预框架的发展和与OMHSP强有力的伙伴关系的结果将最大限度地提高 将研究成果转化为实践。

Background. Depression is a highly prevalent mental health disorder that carries a heavy disease burden and is the 2nd leading risk factor for suicide among Veterans. VA has disseminated three effective psychotherapies for depression to VA clinics but therapist use of these treatments is <12%. Surprisingly, no studies have examined the provision of evidence-based psychotherapies for depression (D-EBPs) in VA and reasons underlying infrequent delivery, leaving a critical gap in depression care delivery in VA. System factors are a known driver of EBP use, and early signs from OMHSP's efforts and unique factors related to how depression care is organized in VA warrant an empirical investigation. Significance. Low utilization of D-EBPs and the lack of empirical evidence on barriers is a significant problem for several reasons. First, suicide prevention is a top priority in VA and across the nation and untreated depression is a major risk factor for suicide. Second, effectiveness of existing interventions that target provider-level barriers cannot be maximized without data about system barriers. Increasing the reach of other EBPs (e.g., PTSD) has required intervention at all levels (patient, provider, and system) and the same is undoubtably true for D-EBPs. Identifying and targeting system factors and exploring therapist factors and conducting the first exploration of patient perceptions of D-EBPs will bolster these early provider-focused interventions. Furthermore, this proposal is timely in that it comes on the heels of OMHSP's shift from assessing anticipated barriers to D-EBP delivery during trainings to developing partnerships to understand barriers experienced in the field. Finally, since this proposal is examining D-EBP delivery in specialty mental health clinics where other mental health conditions are treated, findings have implications of EBPs for those other conditions. Innovation/Impact. The proposed 3.5-year study will be the first study to examine reasons for low utilization of depression EBPs by therapists in VA. Our mixed-methods approach will yield a robust understanding of how the policies, resources and culture within specialty mental health clinics contribute to low D-EBP use by therapists. Our aims are directly aligned with OMHSP's goal to increase the implementation of clinical practice guideline-concordant care in VA mental health clinics. Our proposed classification of all VA medical centers on system-level factors that are associated with D-EBP delivery, strategic qualitative analysis, intervention mapping and stakeholder engagement provides invaluable data to OMHSP and the field quickly. Aims. 1) Quantitatively examine the association between health system factors and D-EBP delivery; 2) Qualitatively examine how contextual and system factors impact therapist decisions around the provision of D-EBPs; 3) Develop a framework of intervention targets and potential solutions to reduce barriers to D-EBP use; 4) Secondary/Exploratory Aims: a) Qualitatively explore how therapist factors impact D-EBP use; b) Explore patients' perceptions of D-EBPs. Methodology. Using an explanatory sequential mixed-method design, in Aim 1 (quantitative) we will abstract system-level and EBP training data for FY21 Q3-FY22 Q2. Descriptive statistics of system-level factors and general linear mixed model analysis will be used to characterize facilities and examine associations between system factors and therapists' D-EBP use. This will enable us to quickly understand both the main correlates of D-EBP utilization and variability of these factors across sites, provide critical data to our OMHSP partners and inform selection of sites for Aim 2. Aim 2 and secondary aims (qualitative) will include interviews with therapists trained in the three D-EBPs and mental health leaders from 10 VA medical centers (5 high and 5 low performers; N = 120- 150) and 20 patients to understand their perceptions of D-EBPs. Aim 3 will involve intervention mapping and Delphi strategies to develop a framework for reducing system barriers to D-EBP delivery. Implementation. Findings from our intervention framework development and strong partnership with OMHSP will maximize the translation of study findings into practice.