Modeling Adherence to Psychotherapy for Depression

描述(申请人提供)：大量证据支持心理治疗对抑郁症的疗效。消费者往往更倾向于将心理治疗作为一线治疗。然而，有效的治疗方法未能惠及绝大多数抑郁症患者。在那些寻求抑郁症治疗的人中，四分之一的人没有参加第一次就诊，一半的人在第五次就诊前辍学。检查心理治疗依从性的卫生服务研究明显有限。虽然人们经常假设供应商的特征会影响遵守，但这一假设尚未经过实证检验。之前没有研究过在第一次访问之前就辍学进行过调查。新的以消费者为导向的健康计划(健康储蓄账户和高免赔额计划)对心理治疗的影响尚未得到评估。抑郁症的心理治疗通常与抑郁症的药物治疗或其他医疗条件同时发生，但尚不清楚不同的心理健康或医疗治疗中的坚持行为是否一致。必须消除这些差距，以便制定有效和适当有针对性的干预措施，以提高遵守情况。这里提出的这项研究是了解和增加消费者对有效抑郁症治疗的需求的综合计划的一个组成部分。我们将使用来自大型混合模式卫生系统的数据来检查影响心理治疗依从性的患者、提供者和卫生系统因素。电话分流电话的记录将被用来识别大约40,000名成年人和青少年，他们要求对抑郁症进行初步的心理治疗预约。行政数据(保险索赔、保险覆盖范围、提供者绩效)和提供者调查数据将用于衡量心理治疗依从性的关键预测因素。结合这些关于消费者、提供者和卫生系统特征的不同数据的能力是拟议的研究设置所独有的。坚持的结果包括心理治疗的开始和继续。具体目标集中在四个问题上：1)在考虑了偶然性差异和病例差异后，治疗师之间的依从率有何不同？供应商之间的差异可以用可测量的供应商特征来解释吗？2)遵守是否受到免赔额和自付水平的影响？消费者先前在医疗和心理健康治疗上的支出如何调节成本分担的效果？3)受薪团体模式实践和按服务收费的网络实践之间的坚持有何不同？差异可以用衡量的提供者特征来解释吗？4)坚持心理治疗与坚持伴随的抗抑郁药物治疗或其他医疗条件的伴随治疗有什么关系？我们建议使用来自大型混合模式卫生系统的数据来检查影响心理治疗依从性的患者、提供者和卫生系统因素。这项拟议的研究是正在进行的全面计划的一个组成部分，该计划旨在了解和增加消费者对有效抑郁症治疗的需求。

DESCRIPTION (provided by applicant): Abundant evidence supports the efficacy of psychotherapy for treatment of depression. Consumers often prefer psychotherapy as a first-line treatment. Effective therapy, however, fails to reach the vast majority of people with depressive disorders. Of those who seek therapy for depression, one quarter fail to attend an initial visit and half drop out before the fifth visit. Health services research examining adherence to psychotherapy is remarkably limited. While it is often assumed that provider characteristics influence adherence, this assumption has not been empirically tested. No previous research has examined drop-out prior to the initial visit. The effects of new consumer-directed health plans (Health Savings Accounts and high-deductible plans) on psychotherapy have not been evaluated. Psychotherapy for depression often co- occurs with medication treatment for depression or other medical conditions, but it is not known whether adherence behavior is consistent across different mental health or medical treatments. These gaps must be addressed in order to develop effective and appropriately targeted interventions to improve adherence. The research proposed here is one component of a comprehensive program to understand and increase consumer demand for effective depression treatment. We will use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. Records from telephone triage calls will be used to identify approximately 40,000 adults and adolescents requesting initial psychotherapy appointments for treatment of depression. Administrative data (insurance claims, insurance coverage, provider performance) and provider survey data will be used to measure key predictors of psychotherapy adherence. The ability to combine these diverse data regarding consumer, provider, and health system characteristics is unique to the proposed study setting. Adherence outcomes include psychotherapy initiation and continuation. Specific aims focus on four issues: 1) How do adherence rates differ between therapists after accounting for chance variation and differences in casemix? Can variation between providers be explained by measurable provider characteristics? 2) Is adherence influenced by level of deductibles and co-payments? How is the effect of cost-sharing moderated by consumers' prior spending on medical and mental health treatment? 3) How does adherence differ between salaried group-model practice and fee-for-service network practice? Can differences be explained by measured provider characteristics? 4) How is adherence to psychotherapy associated with adherence to concomitant antidepressant pharmacotherapy or concomitant treatment for other medical conditions? We propose to use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. The proposed research is one component of an ongoing comprehensive program to understand and increase consumer demand for effective depression treatment.