Improving Primary Care Anxiety Treatment Engagement and Effectiveness

初级保健-心理健康一体化方案，其中心理健康保健是在 初级保健（PC）是VHA患者对齐护理团队提供的全人PC的组成部分 （PACT）。焦虑症和阈下症状在PC患者中普遍存在且负担沉重，然而， 焦虑症治疗不足，这表明需要改善目前的焦虑症PC服务。PC-MHI是一种理想的 提供焦虑治疗的背景，但有效的，基于证据的焦虑干预措施是（a） 针对PC-MHI护理的范围和形式设计，（B）有效，（c）以退伍军人为中心，以及（d）能够 需要适应各种焦虑表现（伴或不伴共病抑郁）。的 这项研究的最终目标是开发一种退伍军人可以接受的简短的焦虑干预措施， 提供商在PC-MHI环境中实施的可行性。调整循证治疗的要素 专门为PC-MHI环境设计的干预措施，并呼吁退伍军人可以帮助改善 PC焦虑治疗的参与度和有效性，与VHA蓝图的目标一致， 卓越将退伍军人的治疗偏好纳入干预发展将增强 以患者为中心的护理，以最终提高治疗参与度。供应商的认证 在独特的PC-MHI环境中实施循证治疗的挑战的观点将有助于 确保干预措施在现实世界的临床实践中可行。 Robyn Shepardson博士是综合治疗中心的早期职业临床研究心理学家。 医疗保健（CIH），一个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）的目的是促进博士。 转变为独立的HSR&D调查员，长期目标是增加参与， 有效性，以证据为基础，以退伍军人为中心的干预措施，为常见的心理健康问题， PC-MHI。该CDA-2的短期目标是获得正式培训、专家指导和研究 经验，以促进VHA HSR&D职业生涯的重点是改善退伍军人的PC焦虑治疗方案。 CDA-2将为Shepardson博士提供（1）卫生服务研究方法，（2）简要 焦虑和抑郁的干预措施，（3）混合方法，重点是定性研究，（4） 实施科学，重点是混合有效性-实施试验，以及（5）granecraft， 这将使她能够成功地进行组成CDA-2研究计划的三个连续项目。 目标1，试点数据表明，使用多种循证焦虑治疗的比例较低 技术之间的PC-MHI供应商，将是一个定性研究，以检查供应商的通常护理做法， 决策（特别是使用或不使用各种技术的选择），并获得有关 在现实世界的临床实践中使用循证焦虑干预技术的可行性。这些发现 将告知目标2，在目标2中，我们将调整现有的基于证据的认知行为干预技术 以简短的PC-MHI格式和跨诊断包交付，可以适应各种焦虑 症状表现，包括共病抑郁症状。我们会把目标1的研究结果， 减少供应商的实施挑战，从我们对退伍军人偏好的试点研究中， 治疗形式和内容，以优化以患者为中心的干预措施， 治疗参与。我们将试行由此产生的治疗手册，以获得患者（n = 5）和提供者（n = 3)反馈以完善干预措施。最后，目标3将是第一类有效性-执行混合试点项目 随机对照试验（N = 48）的干预，以评估可行性，可接受性，实施 障碍和促进因素，以及与常规护理相比的有效性。试点试验的结果将告知 在第三年年底前提交一份关于大型混合动力II型试验的HSR&D优点建议书。

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.