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)测试简单行为疗法(Step-up)的有效性 对于从初级保健社区卫生中心招募的患有焦虑和/或抑郁的青少年， (B)评估以人群为基础的逐步实施方法，并(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。焦虑感 情绪障碍在年轻人中很普遍，而且会造成损害，部分原因是当前和终身共病的发生率很高。 由于共同的致病因素。如果不治疗，这些疾病会导致持续的功能损害和 疾病复发和自杀行为的风险增加。只有五分之一的年轻人焦虑，五分之一的年轻人抑郁 报告任何终生精神健康使用情况，这是所有青少年精神健康状况中最低的治疗率。此外， 在护理方面存在明显的差距，少数族裔青年接受服务的可能性明显低于非少数民族青年 西班牙裔白人(Nhw)青年，尽管经历了类似或更高的失调率。因此，有效的 焦虑和抑郁的治疗是一个关键的公共卫生优先事项，特别是在传统上 服务不足的少数族裔青年。Step-Up是一种简化的行为干预措施，旨在有效地治疗 焦虑和抑郁作为一个统一的问题领域，通过瞄准这两种疾病共同的回避行为。 这项拟议的研究建立在一项多点随机试验的基础上，该试验证明了STEEP-UP的有效性， 对西班牙裔年轻人的影响尤其强烈。此应用程序响应RFA-MH-20-400，并侧重于 在疾病控制和预防中心的OCHIN网络和联邦机构中实施和测试这一有前景的循证做法 合格的健康中心，为不同的弱势家庭提供服务。一步步走到了 通过视频访问适应数字健康框架，以提高传播潜力、可扩展性和 成本效益。我们建议进行一项创新的混合有效性-实施研究(类型 1)与传统的门诊精神健康促进转诊相比，测试数字交付的阶梯 服务(照常治疗，TAU)。青年(8-17岁，N=250)将在 通过电子健康记录(EHR)和新病例的临床医生直接转诊达到人口水平。合资格 青少年将被随机分为(A)加强治疗或(B)协助转介到TAU。临床结果将是 在第16周和第32周进行评估，并在护理过程中收集过程中收集的措施。定性访谈 将对20名青年-父母二人组、35名CHC提供者和工作人员以及20名管理员进行抽样调查 注册诊所。目的包括测试加强和介入干预的临床有效性。 家庭中易受伤害的社区卫生保健人口的机制(目标1)，评估进步对公平的影响 在少数群体青年的心理健康成果方面(目标2)，估计实施成本和增量成本 提高工作效率(目标3)，并确定可持续执行工作计划的目标机制 使用《实施研究综合框架》(目标4)在社区卫生中心开展工作。

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).