Improving Depression Management in Primary Care

背景：VA的初级保健-心理健康整合（PC-MHI）植根于循证医学， 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共同 在初级保健中治疗抑郁症。虽然PC-MHI使专家能够支持初级保健患者的药物治疗， 没有及时和充分的心理治疗。需要替代疗法。 意义/影响：抑郁症是致残的，影响五分之一的退伍军人。心理治疗是首选， 退伍军人，但充满了多层次的障碍（例如，工作人员可用性、患者前往诊所的旅行、有限的诊所时间）。 如果不加强现有的PC-MHI模型，使初级保健患者能够更好地获得有效的 心理治疗，退伍军人参与抑郁症治疗是不可能改善。 创新：该CDA旨在缩小VA初级保健患者获得心理治疗的差距， 通过调整PC-MHI协作护理模式来改善对计算机认知的吸收， 行为疗法（cCBT）。cCBT可以通过互联网24/7访问，并有效地治疗抑郁症， 超过30次试验。在适度的专家支持下，它并不比面对面的心理治疗差。PC-MHI 可以促进退伍军人对cCBT的吸收，使用基于证据的协作护理模式提供以下内容- 最有效的cCBT试验的特点是护理管理和心理健康专家的支持。 具体目标：这个CDA将使我成为一个VA实施科学家谁设计，测试，实施， 并传播有效的合作护理模式的改进，以治疗抑郁症的初级保健。我 具体目标是：（1）调整PC-MHI协作护理，以提高VA初级护理中cCBT的使用率 抑郁症患者，基于多层次利益相关者的输入;（2）初步测试可行性， cCBT增强的协作护理对退伍军人抑郁症状的可接受性和潜在影响 以及一个初级保健诊所的相关结果，为更大的多站点混合有效性做准备- （3）就将试点结果转化为 cCBT增强的协作护理在VA的地方，区域和国家都是可行的。 方法论：在目标1中，我将使用定性方法，并从退伍军人，VA提供者， 国家专家和业务领导人（CDA咨询小组）的其他主要利益相关者，以适应PC-MHI 协作护理模式，以提高cCBT的吸收。在目标2中，我将进行一项试点随机对照试验， (RCT)检查可行性、可接受性和对抑郁症、患者激活和健康的潜在影响- 接受（1）cCBT增强的VA初级保健抑郁症患者的相关生活质量 协作治疗（n=32）或（2）常规治疗（n=32），西洛杉矶VA，从基线至2个月（治疗后 干预）。该试点将使我能够进行多中心混合I型有效性-实施RCT。 在目标3中，我将使用修改后的德尔菲方法建立一个虚拟专家小组，以检查关键障碍， cCBT增强型协作护理模式中的促进者，以缩小心理治疗获取方面的差距， 患有抑郁症和其他疾病的退伍军人在常规VA初级保健，这将被告知现有的 文献和基于VA的试点数据。CDA的培训和指导将有助于我过渡到一个 独立的VA HSR&D调查员，填补了实施科学（和定性）方面的明确培训空白 方法），临床试验设计（抑郁症护理）和健康信息学。 后续步骤/实施：调整PC-MHI的协作护理模式以纳入cCBT可以改善 获得心理治疗，并吸引约40万未经治疗的抑郁症退伍军人， 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 导师和培训，开始我的职业生涯作为一个实施科学家谁领导协作护理模式 使用新技术来解决退伍军人在初级保健中未满足的需求和偏好。

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.