Improving Primary Care Anxiety Treatment Engagement and Effectiveness

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Primary Care-Mental Health Integration (PC-MHI), in which mental health care is provided within primary care (PC), is an integral component of whole-person PC provided by VHA Patient Aligned Care Teams (PACT). Anxiety disorders and subthreshold symptoms are prevalent and burdensome among PC patients, yet anxiety is under-treated, suggesting a need to improve current PC services for anxiety. PC-MHI is an ideal context in which to provide anxiety treatment, but effective, evidence-based anxiety interventions that are (a) designed for the scope and format of PC-MHI care, (b) effective, (c) Veteran-centered, and (d) able to accommodate a variety of anxiety presentations (with or without comorbid depression) are needed. The ultimate goal of this research is to develop a brief anxiety intervention that will be acceptable to Veterans and feasible for providers to implement in the PC-MHI setting. Adapting elements of evidence-based treatments into an intervention designed specifically for the PC-MHI setting and to appeal to Veterans can help to improve PC anxiety treatment engagement and effectiveness, consistent with the goals of the VHA Blueprint for Excellence. Incorporating Veterans’ treatment preferences into intervention development will enhance the patient-centeredness of care to ultimately improve treatment engagement. Incorporating providers’ perspectives on challenges in implementing evidence-based treatment in the unique PC-MHI setting will help ensure that the intervention is feasible to implement in real-world clinical practice. Dr. Robyn Shepardson is an early career clinical research psychologist at the Center for Integrated Healthcare (CIH), a VHA Mental Health Center of Excellence charged with improving Veteran healthcare through PC-MHI. The purpose of this Career Development Award-2 (CDA-2) is to facilitate Dr. Shepardson’s transition into an independent HSR&D investigator with a long-term objective of increasing engagement in, and effectiveness of, evidence-based, Veteran-centered interventions for common mental health concerns within PC-MHI. The short-term objective of this CDA-2 is to obtain formal training, expert mentorship, and research experience to facilitate a VHA HSR&D career focused on improving PC anxiety treatment options for Veterans. The CDA-2 will provide Dr. Shepardson with needed training in (1) health services research methods, (2) brief interventions for anxiety and depression, (3) mixed methods with a focus on qualitative research, (4) implementation science with a focus on hybrid effectiveness-implementation trials, and (5) grantsmanship, which will allow her to successfully conduct the three sequential projects comprising the CDA-2 research plan. Aim 1, informed by pilot data indicating low rates of using numerous evidence-based anxiety treatment techniques among PC-MHI providers, will be a qualitative study to examine providers’ usual care practices and decision-making (particularly choices to use or not use various techniques) and to obtain feedback on the feasibility of using evidence-based anxiety intervention techniques in real-world clinical practice. These findings will inform Aim 2, in which we will adapt existing evidence-based, cognitive-behavioral intervention techniques for delivery in a brief PC-MHI format and transdiagnostic package that can accommodate a variety of anxiety symptom presentations, including comorbid depressive symptoms. We will incorporate findings from Aim 1 to reduce implementation challenges for providers, and from our pilot study on Veterans’ preferences regarding treatment format and content to optimize patient-centeredness of the intervention in an effort to enhance treatment engagement. We will pilot the resulting treatment manual to obtain patient (n = 5) and provider (n = 3) feedback to refine the intervention. Finally, Aim 3 will be a hybrid type I effectiveness-implementation pilot randomized controlled trial (N = 48) of the intervention to evaluate feasibility, acceptability, implementation barriers and facilitators, and effectiveness compared to usual care. Results of the pilot trial will inform submission of an HSR&D merit proposal for a larger hybrid type II trial to be submitted by the end of Year 3.