Improving Depression Management in Primary Care

改善初级保健中的抑郁症管理

• 批准号: 10186554
• 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/10186554
• 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; 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; 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; 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：退伍军人管理局的初级保健-心理健康一体化 (PC-MHI) 植根于循证医学 协作护理模式，护理管理者、心理健康专家和初级保健提供者共同参与 在初级保健中治疗抑郁症，而 PC-MHI 使专家能够支持初级保健中的药物治疗。 护理、及时和充分的心理治疗是不可能的。 意义/影响：抑郁症会导致五分之一的退伍军人首选心理治疗。 退伍军人，但充满了多层次的障碍（例如，工作人员的可用性、患者前往诊所、有限的诊所时间）。 如果没有现有的增强型 PC-MHI 模型，就无法使初级保健患者更好地获得有效的治疗 心理治疗方面，退伍军人对抑郁症治疗的参与度不太可能有所改善。 创新：该 CDA 旨在缩小 VA 初级保健患者在获得心理治疗方面的差距 通过采用 PC-MHI 协作护理模型来改善计算机认知的采用来治疗抑郁症 行为疗法 (cCBT) 可通过互联网 24/7 获取，并已有效治疗抑郁症。 经过 30 多项试验，在适当的专家支持下，它并不逊色于面对面的 PC-MHI。 可以促进退伍军人接受 cCBT，使用基于证据的协作护理模型来提供以下内容： 护理管理和心理健康专家支持是最有效的 cCBT 试验的特点。 具体目标：该 CDA 将使我成为一名 VA 实施科学家，负责设计、测试、实施、 并传播有效的协作护理模式改进，以治疗初级保健中的抑郁症。 具体目标是：(1) 调整 PC-MHI 协作护理，以提高 VA 初级护理对 cCBT 的采用 抑郁症患者，根据多级利益相关者的意见；（2）试点测试可行性， 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 和一个初级保健诊所的相关结果，为更大的、多地点的混合有效性做准备- 实施试验；(3) 就将试点结果转化为设计达成专家共识 cCBT 增强的协作护理在退伍军人事务部在当地、区域和全国范围内都是可行的。 方法：在目标 1 中，我将使用定性方法并征求退伍军人、VA 提供者和 国家专家和运营领导者（CDA 咨询小组）的其他主要利益相关者，以适应 PC-MHI 在目标 2 中，我将进行一项试点随机对照试验。 （随机对照试验）检查可行性、可接受性以及对抑郁、患者激活和健康的潜在影响 接受 (1) cCBT 增强治疗的 VA 初级保健抑郁症患者的相关生活质量 弗吉尼亚州西洛杉矶的协作护理 (n=32) 或 (2) 常规护理 (n=32)，从基线到 2 个月（术后） 该试点项目将使我能够开展多地点混合 I 类有效性实施随机对照试验。 在目标 3 中，我将使用修改后的德尔菲方法进行虚拟专家小组检查关键障碍和 cCBT 增强型协作护理模式的促进者，旨在缩小心理治疗获取方面的差距 患有抑郁症和其他疾病的退伍军人在常规 VA 初级保健中，将通过现有的信息了解情况 CDA 培训和指导将有助于我过渡到 VA 的试点数据。 独立的 VA HSR&D 调查员通过填补实施科学（和定性）方面的明确培训空白 方法）、临床试验设计（抑郁症护理）和健康信息学。 后续步骤/实施：调整 PC-MHI 的协作护理模式以纳入 cCBT 可以改善 获得心理治疗，并让大约 400,000 名未经治疗的患有抑郁症的退伍军人参与进来 心理治疗，尤其是寻求 CDA 便利护理的 OIF/OEF/OND 退伍军人。 指导和培训，开始我作为领导协作护理模式的实施科学家的职业生涯 使用新技术来解决初级保健中退伍军人未满足的需求和偏好进行改进。