Increasing Access to Care through Guided Self-Help Treatments for Depression and Anxiety in VAPrimary Care-Mental Health Integration

About This Grant

Significance to VA: Elevated symptoms of depression and generalized anxiety disorder (GAD) are present in 10% and 8% of Veterans respectively and are associated with functional impairment and suicidality. Cognitive behavioral therapy (CBT) is a first line intervention for these conditions, yet few Veterans receive this treatment, in part due to the limited availability of mental health providers trained in CBT. The stepped care model offers one approach to addressing access by offering effective yet less resource-intensive treatments upon entry into mental health care for individuals with mild to moderate symptoms, stepping up the intensity and level of care as needed. Guided self-help (GSH) is one low intensity treatment format that could increase accessibility of CBT for depression and GAD. In GSH, patients follow a self-help version of an evidence-based behavioral intervention with coaching from a provider. A meta-analysis found that GSH is as effective as traditional psychotherapy treatments for depression and anxiety disorders. VHA’s Primary Care Mental Health- Integration (PCMHI) Service may be the ideal setting in which to deploy GSH. However, GSH is not widely used within VHA, and existing CBT interventions for depression and GAD would require adaptation to the GSH format and PCMHI setting and would benefit from Veteran input. One critical question is whether GSH can be feasibly delivered by non-psychologists, such as social workers and/or health coaches, to help address mental health access. This research may increase Veteran access to care through the availability of efficient, evidence-based programs at a lower level of the stepped care model of mental health treatment. Building Veteran-centered programs by incorporating Veteran feedback throughout the process may increase engagement with care. Overall, the project aligns with the VA strategic priority of implementation science. Innovation and Impact: This project proposes to innovate current practices in a lower level of the stepped care model of mental health treatment in VHA by providing GSH programs for prevalent conditions. If these programs can be feasibility delivered by non-psychologists, this has the potential to increase access to mental health care for Veterans, reduce costs to VHA over time, and help connect Veterans to soonest and best care. Specific Aims: The specific aims of this project are to 1) Conduct a formative evaluation assessing barriers and facilitators to the use of GSH for symptoms of depression and GAD in PCMHI via a national survey and qualitative interviews with PCMHI providers and clinic administrators, 2) Refine and conduct a pilot randomized trial of Behavioral Activation-GSH (BA-GSH) for depression (15 Veterans assigned to BA-GSH; 15 assigned to treatment as usual) in PCMHI as delivered by a group of non-psychologists. This pilot will evaluate the acceptability and feasibility of BA-GSH and explore preliminary effectiveness, and 3) Through iterative intervention design and adaptation, integrate Veteran feedback to adapt an existing CBT for GAD intervention (GSH-GAD) for delivery in PCMHI and conduct an open trial pilot of GSH-GAD with 10 Veterans in PCMHI. Methodology: For Aim 1, sequential explanatory mixed-methods evaluation will be used to identify barriers and facilitators to implementing GSH programs in PCMHI and as well as which provider type may be best suited to deliver GSH. For Aim 2, a randomized pilot trial will evaluate the feasibility and acceptability of a GSH program (BA-GSH) for symptoms of depression through qualitative interviews and an exploratory pre-post comparison of symptoms. For Aim 3, iterative intervention design and adaptation will be used to adapt a GSH program for symptoms of GAD. The resulting program will be evaluated in 10 Veterans through an open pilot. Path to Translation/Implementation: The training, piloting of methods, preparation of GSH programs for future implementation, and information gathered through this research will prepare Dr. Plasencia for becoming an independent VA investigator. With an initial focus on GSH, her work will seek to increase access to care by developing effective and Veteran-centered programs for mental health in VHA.