Modeling Adherence to Psychotherapy for Depression

描述（由申请人提供）：大量证据支持心理疗法治疗抑郁症的疗效。消费者往往更喜欢心理治疗作为一线治疗。然而，有效的治疗未能达到绝大多数抑郁症患者。在那些寻求抑郁症治疗的人中，四分之一的人没有参加第一次访问，一半人在第五次访问之前退出。卫生服务研究坚持心理治疗是非常有限的。虽然人们通常认为，供应商的特点影响遵守，这一假设尚未得到实证检验。以前没有研究调查过初次访视前的辍学情况。尚未评估新的消费者导向的健康计划（健康储蓄账户和高免赔额计划）对心理治疗的影响。抑郁症的心理治疗通常与抑郁症或其他医疗条件的药物治疗同时发生，但目前尚不清楚坚持行为是否在不同的心理健康或医疗治疗中是一致的。必须弥补这些差距，以便制定有效和有适当针对性的干预措施，提高遵守率。这里提出的研究是一个全面计划的一部分，以了解和增加消费者对有效抑郁症治疗的需求。我们将使用来自一个大型混合模式卫生系统的数据来研究影响心理治疗依从性的患者、提供者和卫生系统因素。电话分类电话记录将用于确定大约40，000名成年人和青少年，他们要求进行抑郁症治疗的初步心理治疗预约。管理数据（保险索赔，保险范围，提供者的表现）和提供者的调查数据将用于衡量心理治疗依从性的关键预测因素。联合收割机能够将这些关于消费者、提供者和卫生系统特征的不同数据结合起来，这是拟定研究环境所独有的。依从性结果包括心理治疗的开始和继续。具体的目标集中在四个问题：1）如何坚持率不同的治疗师占机会变化和差异的病例组合后？供应商之间的差异可以用可衡量的供应商特征来解释吗？2)依从性是否受到免赔额和共付额水平的影响？消费者在医疗和心理健康治疗上的先前支出如何调节成本分担的效果？3)受薪群体模式实践和收费服务网络实践之间的依从性有何不同？差异是否可以用衡量的提供者特征来解释？4)心理治疗的依从性如何与伴随抗抑郁药物治疗或伴随其他疾病治疗的依从性相关？我们建议使用一个大型的混合模式的卫生系统的数据来检查患者，供应商和卫生系统的因素影响坚持心理治疗。这项研究是一项正在进行的综合计划的一部分，旨在了解和增加消费者对有效抑郁症治疗的需求。

DESCRIPTION (provided by applicant): Abundant evidence supports the efficacy of psychotherapy for treatment of depression. Consumers often prefer psychotherapy as a first-line treatment. Effective therapy, however, fails to reach the vast majority of people with depressive disorders. Of those who seek therapy for depression, one quarter fail to attend an initial visit and half drop out before the fifth visit. Health services research examining adherence to psychotherapy is remarkably limited. While it is often assumed that provider characteristics influence adherence, this assumption has not been empirically tested. No previous research has examined drop-out prior to the initial visit. The effects of new consumer-directed health plans (Health Savings Accounts and high-deductible plans) on psychotherapy have not been evaluated. Psychotherapy for depression often co- occurs with medication treatment for depression or other medical conditions, but it is not known whether adherence behavior is consistent across different mental health or medical treatments. These gaps must be addressed in order to develop effective and appropriately targeted interventions to improve adherence. The research proposed here is one component of a comprehensive program to understand and increase consumer demand for effective depression treatment. We will use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. Records from telephone triage calls will be used to identify approximately 40,000 adults and adolescents requesting initial psychotherapy appointments for treatment of depression. Administrative data (insurance claims, insurance coverage, provider performance) and provider survey data will be used to measure key predictors of psychotherapy adherence. The ability to combine these diverse data regarding consumer, provider, and health system characteristics is unique to the proposed study setting. Adherence outcomes include psychotherapy initiation and continuation. Specific aims focus on four issues: 1) How do adherence rates differ between therapists after accounting for chance variation and differences in casemix? Can variation between providers be explained by measurable provider characteristics? 2) Is adherence influenced by level of deductibles and co-payments? How is the effect of cost-sharing moderated by consumers' prior spending on medical and mental health treatment? 3) How does adherence differ between salaried group-model practice and fee-for-service network practice? Can differences be explained by measured provider characteristics? 4) How is adherence to psychotherapy associated with adherence to concomitant antidepressant pharmacotherapy or concomitant treatment for other medical conditions? We propose to use data from a large mixed-model health system to examine patient, provider, and health system factors influencing adherence to psychotherapy. The proposed research is one component of an ongoing comprehensive program to understand and increase consumer demand for effective depression treatment.