Effectiveness and Implementation of Brief Cognitive Behavioral Therapy in CBOCs

描述(由申请人提供)： 这项拟议的研究将检验在退伍军人管理局社区门诊(CBOC)治疗的抑郁症退伍军人的简短认知行为疗法(BCBT)的临床影响和实施潜力。这项研究的意义是多方面的，将提供：1)关于bCBT在CBOC环境下对退伍军人的有效性的临床数据；2)对目前难以将循证心理疗法纳入其临床实践的现有CBOC临床医生的培训和临床支持；3)高度灵活的bCBT干预措施，有可能接触到原本可能得不到治疗的退伍军人；以及4)提供关于帮助CBOC临床医生使用结构化bCBT的实施战略影响的初步数据。抑郁症是一种严重的健康状况，给患者和医疗保健系统带来了巨大的负担，在退伍军人中尤其普遍。2008年，退伍军人健康管理局发布了《统一精神健康服务手册》，以努力扩大为患有抑郁症的退伍军人提供的精神健康服务，包括 扩大初级保健和CBOC环境的服务。尽管退伍军人管理局在心理健康服务方面仍然是全国领先的，但退伍军人管理局提供的心理治疗是有限的，特别是对在CBOC环境中接受护理的退伍军人。目前，需要努力帮助CBOC临床医生和其他利益相关者解决在CBOC中使用循证心理治疗的临床有效性和实践障碍。目标1将寻求确定在治疗后(4个月)以及8个月和12个月的随访中，抑郁结果是否作为干预(由CBOC临床医生提供的bCBT与加强的常规护理相比)的功能而不同。目标2将使用混合方法形成性评估来了解与bCBT的可行性、采用和实施相关的背景因素。形成性评估将在实施之前、期间和之后进行，包括需求评估、临床和实施方法的修改以及数据的收集和解释。这项拟议的为期4年的多点试验旨在使用有效性-实施混合型2设计来检查退伍军人抑郁症患者的bCBT干预，该干预由退伍军人CBOC诊所现有的精神卫生提供者提供。临床效果将侧重于使用模块化的bCBT干预抑郁症，改编自PI之前和正在进行的初级保健环境中与退伍军人的工作。总共将从休斯顿和俄克拉何马城VAMC站内的CBOC诊所招募232名临床上有抑郁症症状的退伍军人(每个站8个CBOC)。符合条件的退伍军人将被随机分配到bCBT或增强型日常护理(EUC)分支机构，参与者的抑郁信息将通过抑郁工具包传达给退伍军人，并通过电子医疗记录传递给退伍军人管理局提供者。拟议的执行战略将通过CBOC和国家利益攸关方进行审查和修改，该战略由PARHIS框架提供信息，并在正在进行的退伍军人管理局试验中进行测试。全面的形成性评估将寻求了解利益攸关方的需求，修改拟议的战略(例如，治疗材料、在线临床医生培训、审计和反馈以及促进)，并评估实施结果。根据RE-AIM和PARHiS框架的信息，第二个目标将探索针对CBOCs的bCBT的证据、背景和便利，结果与可行性、可接受性和对护理的影响有关。

DESCRIPTION (provided by applicant): The proposed study will examine the clinical impact and implementation potential of a brief cognitive behavioral therapy (bCBT) for depressed Veterans treated in VA Community-Based Outpatient Clinics (CBOCs). The implications of this study are multifaceted and will provide: 1) clinical data on the effectiveness of bCBT for Veterans in CBOC settings; 2) training and clinical support to existing CBOC clinicians who currently struggle to incorporate evidence-based psychotherapies into their clinical practice; 3) a bCBT intervention that is highly flexible and holds the potential to reach Veterans who might otherwise go untreated; and 4) provide preliminary data on the impact of an implementation strategy to aid CBOC clinicians in the use of a structured bCBT. Depression is a serious health condition that places tremendous burden on patients and healthcare systems and is especially prevalent in Veterans. In 2008, the Veterans Health Administration released the Uniform Mental Health Services Handbook in an effort to expand the availability of mental health services for Veterans with depression, including expansion of services for primary care and CBOC settings. Although the VA remains a national leader in mental health services, the provision of psychotherapy within VA is limited, especially for Veterans cared for in CBOC settings. Currently, efforts are needed to assist CBOC clinicians and other stakeholders to address clinical effectiveness and practice barriers related to the utilization of evidence-based psychotherapy in CBOCs. Aim 1 will seek to determine whether depression outcomes differ as a function of the intervention (bCBT provided by CBOC clinicians vs. enhanced usual care) at post-treatment (4-month), and 8- and 12-month follow-up. Aim 2 will use a mixed-method formative evaluation to understand the contextual factors related to bCBT feasibility, adoption, and implementation. Formative evaluation will occur before, during, and after implementation and include a needs assessment, modifications to the clinical and implementation approaches, and collection and interpretation of data. The proposed 4-year multi-site trial seeks to use an effectiveness-implementation hybrid type 2 design to examine a bCBT intervention for Veterans with depression as delivered by existing mental health providers in VA CBOC clinics. Clinical effectiveness will focus on the use of a modular bCBT intervention for depression adapted from the PI's prior and ongoing work with Veterans in the primary care setting. A total of 232 Veterans with clinically elevated symptoms of depression will be recruited from CBOC clinics within the Houston and Oklahoma City VAMC stations (8 CBOCs per station). Eligible Veterans will be randomized to either bCBT or to an Enhanced Usual Care (EUC) arm where participant depression information will be conveyed to the Veteran through a depression tool kit as well as to VA providers through the electronic medical record. The proposed implementation strategy, informed by the PARHis framework and tested in an ongoing VA trial, will be vetted and modified through CBOC and national stakeholders. A comprehensive formative evaluation will seek to understand stakeholder needs, modify the proposed strategies (e.g. treatment materials, online clinician training, audit and feedback, and facilitation) and to assess implementation outcomes. As informed by the RE-AIM and PARHiS frameworks, the second aim will explore evidence, context, and facilitation of bCBT for CBOCs with outcomes related to feasibility, acceptability, and impact on care.