Video-visit behavior therapy for anxiety and depression in youth: A randomized effectiveness-implementation study in low-resource primary care settings.

拟议的混合方法研究将（a）测试短期行为治疗（STEP-UP）的有效性 对于从初级保健社区卫生中心（CHC）招募的患有焦虑和/或抑郁的青少年， (b)评估基于人群的STEP-UP实施方法，以及（c）探索患者、提供者和 临床反应，以确定成功和可持续实施的目标机制。焦虑 青年人的情绪障碍是普遍的和有害的， 因为有共同的病因未经治疗，这些疾病导致持续的功能障碍，并传达 复发性疾病和自杀行为的风险增加。只有五分之一的焦虑和五分之二的抑郁青年 报告任何终身精神健康使用，任何青年精神健康状况的最低治疗率。此外，本发明还 在照顾方面存在着明显的差距，少数民族青年接受服务的可能性比非少数民族青年低得多， 西班牙裔白色（NHW）青年，尽管经历类似或更高的疾病率。因此，有效 治疗焦虑和抑郁症是一个关键的公共卫生优先事项，特别是对传统的 服务不足的少数民族青年STEP-UP是一种简化的行为干预，旨在有效治疗 焦虑和抑郁作为一个统一的问题领域，针对回避行为共同的两种疾病。 这项拟议的研究建立在一项多中心随机试验的基础上，该试验证明了STEP-UP的有效性， 尤其是对西班牙裔年轻人的影响。本应用程序响应RFA-MH-20-400，重点关注 在OCHIN的CHC网络和联邦政府中实施和测试这种有前途的循证实践， 合格的保健中心，为各种弱势家庭人口提供服务。STEP-UP已经 适应数字健康框架，通过视频访问增加传播潜力、可扩展性， 成本效益。我们建议进行一项创新的混合效益-实施研究（类型 1)测试数字化交付的STEP-UP与传统门诊心理健康的便利转诊相比 常规治疗（treatment-as-usual，TAU）。青年（8-17岁，N = 250）将在 通过电子健康记录（EHR）和新病例的直接临床医生转诊来提高人口水平。资格 青少年将被随机分配到（a）STEP-UP或（B）TAU。临床结局将是 在第16周和第32周进行评估，并在护理过程中收集过程测量值。定性访谈 将发生与20个青年父母的二人组，35 CHC提供者和工作人员，20名管理人员抽样从 注册诊所目的包括测试STEP-UP的临床有效性和干预的参与 家庭中弱势社区卫生保健人口的机制（目标1），评估加强方案对公平的影响 少数民族青年的心理健康结果（目标2），估计实施成本和增量成本 加强方案的有效性（目标3），并确定可持续执行加强方案的目标机制， 使用实施研究综合框架（目标4）在社区卫生中心开展普及初等教育。

The proposed mixed-methods study will (a) test the effectiveness of brief behavioral therapy (STEP-UP) for youths with anxiety and/or depression recruited from primary care community health centers (CHCs), (b) evaluate a population-based method of implementation of STEP-UP, and (c) explore patient, provider, and clinic reactions to identify target mechanisms for successful and sustainable implementation. Anxiety and mood disorders in youth are prevalent and impairing, with a high current and lifetime comorbidity in part due to shared etiologic factors. Untreated, these disorders lead to sustained functional impairment and convey increased risk for recurrent disorder and suicidal behavior. Only 1 in 5 anxious and 2 in 5 depressed youth report any lifetime mental health use, the lowest treatment rates for any youth mental health condition. Further, there are notable disparities in care, with minority youths significantly less likely to receive services than non- Hispanic white (NHW) youths, despite experiencing similar or higher rates of disorder. Therefore, effective treatment of anxiety and depression is a critical public health priority, especially for traditionally underserved minority youths. STEP-UP is a streamlined behavioral intervention developed to efficiently treat anxiety and depression as a unified problem area by targeting avoidance behavior common to both disorders. The proposed study builds on a multi-site randomized trial demonstrating the effectiveness of STEP-UP, with especially strong effects for Hispanic youths. This application responds to RFA-MH-20-400 and focuses on implementing and testing this promising evidence-based practice in the OCHIN network of CHCs and federally qualified health centers which serves a diverse population of vulnerable families. STEP-UP has been adapted to a digital health framework with video visits to increase dissemination potential, scalability, and cost-effectiveness. We propose to conduct an innovative hybrid effectiveness-implementation study (type 1) testing digitally delivered STEP-UP compared to facilitated referral to traditional outpatient mental health services (treatment-as-usual, TAU). Youths (age 8-17, N = 250) will be identified and recruited at the population level through electronic health records (EHR) and direct clinician referral of new cases. Eligible youths will be randomized to (a) STEP-UP or (b) facilitated referral to TAU. Clinical outcomes will be assessed at Weeks 16 and 32 and process measures collected over the course of care. Qualitative interviews will occur with 20 youth-parent dyads, 35 CHC providers and staff, and 20 administrators sampled from enrolled clinics. Aims include testing the clinical effectiveness of STEP-UP and engagement of the intervention mechanism in the vulnerable CHC population of families (Aim 1), evaluating the impact of STEP-UP on equity in mental health outcomes for minority youths (Aim 2), estimating the implementation cost and incremental cost effectiveness of STEP-UP (Aim 3), and identifying target mechanisms for sustainable implementation of STEP- UP in CHCs using the Consolidated Framework for Implementation Research (Aim 4).