Improving Primary Care Anxiety Treatment Engagement and Effectiveness

初级保健-精神卫生一体化(PC-MHI)，其中精神卫生保健在以下方面提供 初级护理(PC)是VHA患者导向护理团队提供的全人PC的重要组成部分 (公约)。焦虑症和阈值下症状在PC患者中很普遍，也很负担，但 焦虑症没有得到充分治疗，这表明有必要改善目前针对焦虑症的PC服务。PC-MHI是理想的选择 提供焦虑治疗的背景，但有效的循证焦虑干预是：(A) 为PC-MHI护理的范围和形式而设计，(B)有效，(C)以退伍军人为中心，以及(D)能够 适应不同的焦虑表现(有或不伴有抑郁)是必要的。这个 这项研究的最终目标是开发一种简短的焦虑干预措施，使退伍军人和 提供商在PC-MHI设置中实施是可行的。调整循证治疗的要素 进入专门为PC-MHI环境设计的干预并吸引退伍军人可以帮助改善 PC焦虑症治疗参与度和有效性，与VHA蓝图的目标一致 太棒了。将退伍军人的治疗偏好纳入干预开发将增强 以患者为中心的护理，最终提高治疗参与度。合并提供商的 对在独特的PC-MHI环境下实施循证治疗的挑战的看法将有所帮助 确保干预措施在现实世界的临床实践中实施是可行的。 罗宾·谢帕德森博士是一名职业生涯早期的临床研究心理学家，供职于综合心理健康中心。 医疗保健(CIH)，VHA精神健康卓越中心，负责改善退伍军人医疗保健 通过PC-MHI。这个职业发展奖-2(CDA-2)的目的是为了促进Shepardson博士 转变为独立的HSR&D调查员，长期目标是增加参与和 以证据为基础、以退伍军人为中心的干预措施对以下领域常见心理健康问题的有效性 PC-MHI。CDA-2的短期目标是获得正式培训、专家指导和研究 促进VHA HSR&D职业生涯的经验，重点是改善退伍军人的PC焦虑治疗选择。 CDA-2将为Shepardson博士提供(1)卫生服务研究方法，(2)简要 焦虑和抑郁的干预，(3)以定性研究为重点的混合方法，(4) 侧重于混合有效性的实施科学--实施试验，以及(5)赠款， 这将使她能够成功地开展组成CDA-2研究计划的三个连续项目。 目标1，飞行员数据显示使用大量循证焦虑症治疗的比率较低 PC-MHI提供者之间的技术，将是一项定性研究，以检查提供者的通常护理做法和 决策(特别是选择使用或不使用各种技术)，并获得关于 循证焦虑干预技术在现实世界临床实践中的可行性。这些发现 将告知目标2，在该目标中，我们将采用现有的基于证据的认知行为干预技术 以简短的PC-MHI格式和可容纳各种焦虑的跨诊断包进行交付 症状表现，包括共病的抑郁症状。我们将把目标1的调查结果纳入 减少提供商的实施挑战，以及我们对退伍军人偏好的试点研究 优化治疗形式和内容，以患者为中心的干预措施，努力提高 治疗约定。我们将试行最终的治疗手册，以获得患者(n=5)和提供者(n= 3)反馈完善干预措施。最后，目标3将是一种混合的第一类效力实施试验。 干预措施的随机对照试验(N=48)，以评估干预的可行性、可接受性、实施情况 障碍和促进者，以及与通常护理相比的有效性。试点试验的结果将通知 在第三年年底前提交一份关于更大规模的混合II型试验的HSR&D优点建议。

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.