Veteran Peer-Assisted Computerized Cognitive Behavioral Therapy for Depression

项目背景：抗抑郁药物和循证心理治疗 是治疗抑郁症的有效方法。然而，抗抑郁药物的依从性 继续处于次优状态，并为患者提供接触和保留证据- 抑郁症的基础心理治疗是具有挑战性的。VHA已经做出了重大努力 扩大抑郁症的机会和能力--以循证为基础 心理治疗。然而，在2012年，只有35%的退伍军人抑郁症患者完成了 只有6%的人在14周内完成了8次心理治疗， 充分审判的代理人。 如果患者对抑郁症的治疗的主动性和参与度有所增加 提供及时获得高度灵活的循证治疗选项，例如 一种量身定做的、基于网络的认知行为治疗(CCBT)程序。CCBT 有足够的证据证明有效性在英国是有保障的福利 国家卫生服务，但当它得到临床医生或 其他受信任的个人。VA同行专家，VHA快速增长的员工队伍 心理健康，是支持患者参与抑郁症的理想对象 治疗和cCBT中。有研究表明，同龄人可以促进互联网自我使用 管理工具和同行专家对CCBT的支持可能会增强其完成性 以及通过常规的“签到”和通过提供同级 具体体验，如分享生活体验和塑造自我 管理和恢复。 项目目标：我们将开展同行支持的CCBT的混合型I型RCT 330例新发抑郁症患者的强化日常护理(EUC)对比 三个退伍军人事务部及其相关社区的初级保健。我们的具体目标是 将PS-cCBT与增强型日常护理(EUC)在以下方面进行比较：a)患者有症状， 功能性和以康复为导向的结果，b)抑郁应对技能，抗抑郁药 坚持用药，启动和完成更密集的传统 心理治疗(视症状程度而定)。我们的次要目标是评估 患者、同行和提供者在PS-cCBT与EUC中使用混合方法的体验。 最后，我们的探索性目标是评估潜在的调解人在 抑郁症状或功能状态。 研究设计：这将是一项混合I型随机对照试验。 与增强型日常护理(EUC)相比，支持CCBT的退伍军人中有新的 初级保健中抑郁症的诊断。CCBT计划由8个模块和 将由退伍军人管理局同行专家提供支持，每周联系一次，为期12周。我们会 在12岁和24岁时评估患者的症状、功能和以恢复为导向的结果 随机化后一周。我们还将评估这些问题的潜在调解人 结果。双变量和多变量研究分析将评估两者的影响 在每个评估点和一段时间内学习武器。

Project Background: Antidepressant medications and evidence-based psychotherapies are effective treatments for depression. However, antidepressant medication adherence continues to be suboptimal and offering access to and retaining patients in evidence- based psychotherapies for depression is challenging. The VHA has made major efforts to expand access to and capacity for depression focused evidence-based psychotherapies. However in 2012, only 35% of VA patients with depression completed any psychotherapy visit and only 6% completed 8 psychotherapy visits in 14 weeks, a proxy for an adequate trial. Initiation and engagement in depression treatment may be increased if patients are offered timely access to a highly flexible, evidence-based treatment options, such as a tailored, web-based computerized cognitive-behavioral therapy (cCBT) program. cCBT has sufficient evidence for effectiveness to be a covered benefit in United Kingdom National Health Service, but has much larger effects when it is supported by clinicians or other trusted individuals. VA peer specialists, a rapidly increasing workforce in VHA mental health, are ideal candidates to support patients' engagement in depression treatment and in cCBT. Peers have been shown to promote use of Internet self- management tools, and peer specialist support for cCBT may enhance its completion and overall effectiveness through regular "check ins" and also through providing peer specific experiences, such as sharing of lived experiences and modeling of self management and recovery. Project Objectives: We will conduct a Hybrid Type I RCT of Peer-Supported cCBT versus enhanced usual care (EUC) for 330 patients with new episodes of depression in primary care at three VA sites and their associated CBOCs. Our specific aims are to compare PS-cCBT versus enhanced usual care (EUC) on: a) patient symptomatic, functional, and recovery-oriented outcomes, b) depression coping skills, antidepressant medication adherence, and initiation and completion of more intensive traditional psychotherapy (contingent on symptom level). Our secondary aims are to assess patient, peer, and providers' experiences in PS-cCBT versus EUC using mixed methods. Finally, our exploratory aim is to assess potential mediators of improvements in depressive symptoms or functional status. Study Design: This will be a Hybrid I randomized controlled trial (RCT) of peer- supported cCBT compared to enhanced usual care (EUC) among Veterans with new diagnoses of depression in primary care. The cCBT program consists of 8 modules and will be supported by VA peer specialists with weekly contact for 12 weeks. We will assess patient symptomatic, functional and recovery-oriented outcomes at 12 and 24 week following randomization. We will also assess potential mediators of these outcomes. Bivariate and multivariate study analyses will assess the impact of the two study arms at each assessment point and over time.