Equity in veterans' mental health care: Veterans Affairs medical center clinics versus community-based outpatient clinics

Brief Cognitive-Behavioral Therapy for Depression in Community Clinics: A Hybrid Effectiveness-Implementation Trial

OBJECTIVE

The authors examined whether brief cognitive-behavioral therapy (bCBT) for depression, delivered by mental health providers in community-based outpatient clinics (CBOCs) of the Veterans Health Administration, improved depression outcomes and was feasible and acceptable in clinical settings.

METHODS

The authors used a type-2 hybrid effectiveness-implementation, patient-randomized trial to compare bCBT with enhanced usual care. Participants (N=189) with moderate symptoms of depression (Patient Health Questionnaire-9 [PHQ-9] score ≥10) were enrolled from CBOCs in the southern United States. bCBT (N=109) consisted of three to six sessions, delivered by mental health providers (N=17) as part of routine clinic practices. Providers received comprehensive training and support to facilitate bCBT delivery. Recipients of enhanced usual care (N=80) were given educational materials and encouraged to discuss treatment options with their primary care provider. The primary effectiveness outcome was PHQ-9-assessed depression symptoms posttreatment (4 months after baseline) and at 8- and 12-month follow-ups. Implementation outcomes focused on bCBT dose received, provider fidelity, and satisfaction with bCBT training and support.

RESULTS

bCBT improved depression symptoms (Cohen's d=0.55, p<0.01) relative to enhanced usual care posttreatment, and the improvement was maintained at 8- and 12-month follow-ups (p=0.004). bCBT participants received a mean±SD of 3.7±2.7 sessions (range 0-9), and 64% completed treatment (≥3 sessions). Providers delivered bCBT with fidelity and reported that bCBT training and support were feasible and effective.

CONCLUSIONS

bCBT had a modest treatment footprint of approximately four sessions, was acceptable to participants and providers, was feasible for delivery in CBOCs, and produced meaningful sustained improvements in depression.

Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression

INTRODUCTION

The Veterans Health Administration (VHA) supports the nation's largest primary care-mental health integration (PC-MHI) collaborative care model to increase treatment of mild to moderate common mental disorders in primary care (PC) and refer more severe-complex cases to specialty mental health (SMH) settings. It is unclear how this treatment assignment works in practice.

METHODS

Patients (n = 2610) who sought incident episode VHA treatment for depression completed a baseline self-report questionnaire about depression severity-complexity. Administrative data were used to determine settings and types of treatment during the next 30 days.

RESULTS

Thirty-four percent (34.2%) of depressed patients received treatment in PC settings, 65.8% in SMH settings. PC patients had less severe and fewer comorbid depressive episodes. Patients with lowest severity and/or complexity were most likely to receive PC antidepressant medication treatment; those with highest severity and/or complexity were most likely to receive combined treatment in SMH settings. Assignment of patients across settings and types of treatment was stronger than found in previous civilian studies but less pronounced than expected (cross-validated AUC = 0.50-0.68).

DISCUSSION

By expanding access to evidence-based treatments, VHA's PC-MHI increases consistency of treatment assignment. Reasons for assignment being less pronounced than expected and implications for treatment response will require continued study.

Psychometric assessment of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ)

Adherence to protocol among behavioral health providers working in co-located, collaborative care or Primary Care Behavioral Health settings has rarely been assessed due to limited measurement options. Development of psychometrically sound measures of provider fidelity may improve the translation of these service delivery models into every day practice. One hundred seventy-three integrated behavioral health providers in VA primary care clinics responded to an online questionnaire to assess the reliability and validity of the Primary Care Behavioral Health Provider Adherence Questionnaire (PPAQ). Psychometric assessment resulted in a reliable 48-item measure with two subscales that specified essential and prohibited provider behaviors. The PPAQ demonstrated strong convergent and divergent validity when compared to another measure of health care integration. Known-group comparisons provided partial support for criterion validity. The PPAQ is a reliable and valid self-report of behavioral health provider fidelity with implications for improving provider training, program monitoring, and clinical research.

Extreme makeover: Transformation of the veterans health care system

The veterans health care system administered by the U.S. Department of Veterans Affairs (VA) was established after World War I to provide health care for veterans who suffered from conditions related to their military service. It has grown to be the nation's largest integrated health care system. As the system grew, a number of factors contributed to its becoming increasingly dysfunctional. By the mid-1990s, VA health care was widely criticized for providing fragmented and disjointed care of unpredictable and irregular quality, which was expensive, difficult to access, and insensitive to individual needs. Between 1995 and 1999, the VA health care system was reengineered, focusing especially on management accountability, care coordination, quality improvement, resource allocation, and information management. Numerous systemic changes were implemented, producing dramatically improved quality, service, and operational efficiency. VA health care is now considered among the best in America, and the VA transformation is viewed as a model for health care reform.