Improving Depression Management in Primary Care

改善初级保健中的抑郁症管理

• 批准号: 10460426
• 负责人: Lucinda B Leung
• 金额: --
• 依托单位: VA GREATER LOS ANGELES HEALTHCARE SYSTEM
• 依托单位国家: 美国
• 财政年份: 2020
• 资助国家: 美国
• 起止时间: 2020-07-01 至 2025-06-30
• 项目状态: 未结题
• 来源: https://reporter.nih.gov/project-details/10460426
• 关键词: Address; Affect; Alternative Therapies; Antidepressive Agents; Back; Caring; Case Manager; Clinic; Clinical; Clinical Trials Design; Cognitive Therapy; Complex; Computerized Cognitive Behavioral Therapy; Computers; Consensus; Consult; Data; Data Analyses; Data Collection; Depression screen; Diabetes Mellitus; Drops; Drug Prescriptions; Effectiveness; Evaluation; Feedback; Health system; Hour; Human; Hybrids; Hypertension; Improve Access; Internet; Investigator-Initiated Research; Literature; Los Angeles; Low Back Pain; Mental Depression; Mental Health; Mental Health Services; Mentorship; Methodology; Methods; Modality; Modeling; Outcome; Patient Care; Patients; Pharmaceutical Preparations; Plant Roots; Positioning Attribute; Preparation; Prevalence; Primary Care Physician; Primary Health Care; Provider; Psychotherapy; Public Health Informatics; Qualitative Methods; Quality of Care; Randomized Controlled Trials; Research Personnel; Research Proposals; Scientist; Site; Specialist; Structure; Supervision; Telemedicine; Telephone; Testing; Therapy trial; Time; Training; Translating; Translations; Travel; Veterans; Veterans Health Administration; Work; base; care providers; care seeking; career; chronic depression; collaborative care; depression model; depressive symptoms; design; disability; effective therapy; effectiveness implementation study; effectiveness implementation trial; effectiveness-implementation RCT; evidence base; experience; feasibility testing; follow-up; gaps in access; handheld mobile device; health related quality of life; implementation science; improved; innovation; new technology; operation; pilot test; post intervention; preference; programs; skills; therapy design; treatment as usual; uptake; virtual

Background: VA’s Primary Care–Mental Health Integration (PC-MHI) is rooted in evidence-based collaborative care models, where care managers, mental health specialists, and primary care providers jointly treat depression in primary care. While PC-MHI enabled specialists to support medication treatment in primary care, timely and sufficient access to psychotherapy is unattainable. Alternative therapy modalities are needed. Significance/Impact: Depression is disabling and affects one in five Veterans. Psychotherapy is preferred by Veterans, but fraught with multilevel barriers (e.g., staff availability, patient travel to clinic, limited clinic hours). Without enhancing existing PC-MHI models to enable better primary care patient access to effective psychotherapies, Veteran engagement in depression treatment is unlikely to improve. Innovation: This CDA aims to close the gap in psychotherapy access for VA primary care patients with depression by adapting PC-MHI collaborative care models to improve uptake of computerized cognitive behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in more than 30 trials. With modest specialist support, it is non-inferior to face-to-face psychotherapy. PC-MHI can facilitate Veteran uptake of cCBT, using an evidence-based collaborative care model to provide the follow- up care management and mental health specialist back-up that characterizes the most effective cCBT trials. Specific Aims: This CDA will enable me to be a VA implementation scientist who designs, tests, implements, and disseminates effective collaborative care model improvements to treat depression in primary care. My Specific Aims are: (1) to adapt PC-MHI collaborative care to improve uptake of cCBT among VA primary care patients with depression, based on input from multilevel stakeholders; (2) to pilot test the feasibility, acceptability, and potential effects of cCBT-enhanced collaborative care on Veterans’ depression symptoms and related outcomes in one primary care clinic, in preparation for a larger, multi-site hybrid effectiveness- implementation trial; and (3) to establish expert consensus on the translation of pilot findings into a design for cCBT-enhanced collaborative care that is feasible locally, regionally and nationally in VA. Methodology: In Aim 1, I will use qualitative methods and elicit feedback from Veterans, VA providers, and other key stakeholders of national experts and operations leaders (CDA advisory group) to adapt the PC-MHI collaborative care model to improve cCBT uptake. In Aim 2, I will conduct a pilot randomized controlled trial (RCT) to examine feasibility, acceptability, and potential effects on depression, patient activation, and health- related quality of life in VA primary care patients with depression receiving either (1) cCBT-enhanced collaborative care (n=32) or (2) usual care (n=32) in West Los Angeles VA, from baseline to 2-months (post- intervention). This pilot will position me to conduct a multi-site hybrid type I effectiveness-implementation RCT. In Aim 3, I will conduct a virtual expert panel using modified Delphi methods to examine critical barriers and facilitators in the cCBT-enhanced collaborative care model for closing the gap in psychotherapy access for Veterans with depression and other illnesses in routine VA primary care, which will be informed by existing literature and VA-based pilot data. The CDA training and mentorship will facilitate my transition into an independent VA HSR&D investigator by filling explicit training gaps in implementation science (and qualitative methods), clinical trial design (for depression care), and health informatics. Next Steps/Implementation: Adapting PC-MHI’s collaborative care model to incorporate cCBT can improve access to psychotherapy and engage the ~400,000 untreated Veterans with depression who prefer psychotherapy, especially OIF/OEF/OND Veterans seeking care that is convenient. The CDA will provide mentorship and training to begin my career as an implementation scientist who leads collaborative care model improvements using novel technology to address unmet needs and preferences of Veterans in primary care.

背景：VA的初级保健 - 心理健康整合（PC-MHI）植根于循证 协作护理模型，护理经理，心理健康专家和初级保健提供者共同 治疗初级保健的抑郁症。 PC-MHI使专家可以支持初级药物治疗 护理，及时且足够的心理治疗无法获得。需要替代治疗方式。 意义/影响：抑郁症正在残疾，影响五分之一的退伍军人。心理治疗是首选 退伍军人，但充满了多层次障碍（例如，员工的可用性，患者前往诊所，有限的诊所小时）。 不加强现有的PC-MHI模型以使更好的初级保健患者获得有效 心理治疗，退伍军人参与抑郁症治疗不太可能改善。 创新：此CDA旨在缩小VA初级保健患者心理治疗障碍的差距 通过调整PC-MHI协作护理模型来改善计算机认知的吸收来抑郁症 行为疗法（CCBT）。 CCBT可通过互联网24/7全天候访问，并有效地治疗了抑郁症 超过30次试验。在适度的专家支持下，它不属于面对面的心理治疗。 PC-MHI 可以使用基于证据的协作护理模型来促进CCBT的老兵吸收 CCBT试验最有效的CCBT试验的UP Care Management和心理健康专家备份。 具体目的：此CDA将使我成为VA实施科学家，他设计，测试，工具， 并传播有效的协作护理模型改进，以治疗初级保健中的抑郁症。我的 具体目的是：（1）调整PC-MHI协作护理以改善CCBT在VA初级保健中的吸收 抑郁症患者，基于多级利益相关者的投入； （2）驾驶可行性， CCBT增强协作护理对退伍军人抑郁症状的可接受性和潜在影响 并在一个初级保健诊所的相关结果，以准备更大的多站点混合有效性 - 实施审判； （3）在将试点调查结果转化为设计的专家共识 CCBT增强的合作护理在本地，地区和全国范围内都是可行的。 方法论：在AIM 1中，我将使用定性方法，并引起退伍军人，VA提供者和 国家专家和运营负责人（CDA咨询小组）的其他主要利益相关者以适应PC-MHI 协作护理模型可改善CCBT吸收。在AIM 2中，我将进行一项飞行员随机对照试验 （RCT）检查可行性，可接受性和对抑郁，患者激活和健康的潜在影响 VA初级保健患者的相关生活质量接受（1）CCBT增强 从基线到2个月（后 - 干涉）。该飞行员将使我进行多站点混合型I型有效性 - 实现RCT。 在AIM 3中，我将使用修改的Delphi方法进行虚拟专家小组，以检查关键障碍和 CCBT增强协作护理模型的促进者，以缩小心理治疗访问差距 常规VA初级保健中有抑郁症和其他疾病的退伍军人，现有 文献和基于VA的试点数据。 CDA培训和Mentalship将有助于我的过渡到 独立VA HSR＆D调查员通过填补实施科学的明确培训空白（以及定性 方法），临床试验设计（用于抑郁症护理）和健康信息。 下一步/实施：调整PC-MHI的协作护理模型合并CCBT可以改进 进入心理治疗，并与约有40万名未经治疗的退伍军人与抑郁症一起参与 心理治疗，尤其是OIF/OEF/OND退伍军人，寻求方便的护理。 CDA将提供 识别和培训开始我的职业生涯，成为一名实施科学家，他领导了协作模型 使用新型技术的改进来满足老兵在初级保健中的未满足需求和偏好。