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2015 HSR&D/QUERI National Conference Abstract

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3102 — Effectiveness and Implementation of Brief Cognitive Behavioral Therapy in VA Primary Care Settings

Cully J, Houston COIN; Stanley M, Houston COIN; Kauth M, Houston COIN; Naik A, Houston COIN; Petersen N, Houston COIN; Hundt N, Houston COIN; Sansgiry S, Houston COIN; Kunik M, Houston COIN;

Objectives:
Traditional evidence-based psychotherapies are intensive, requiring 12-16 sessions of care, and are often not feasible for use within non-traditional mental health clinics such as VA's Primary Care Mental Health Integration (PC-MHI) program. The current project sought to test the effectiveness of a brief (six-session) cognitive behavioral therapy (bCBT) and multifaceted implementation strategy to increase bCBT use within two VA Primary Care Mental Health Integration (PC-MHI) programs.

Methods:
This 4-year HSRD funded multi-site patient-randomized trial used a hybrid type 2 implementation-effectiveness design to evaluate whether bCBT was more effective than usual care for veterans with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD) with comorbid symptoms of depression (PHQ-9) and/or anxiety (Beck Anxiety Inventory). The bCBT intervention was tested under real-world conditions using PC-MHI clinicians and sought to improve both mental and physical health patient outcomes. Clinicians (N = 19) at two sites were trained and supported with a multifaceted bCBT implementation strategy that included facilitation and audit and feedback. A total of 302 Veterans were randomized (180 to bCBT and 122 to usual care).

Results:
Significant group differences between bCBT and usual care were found at 4 months for depression (p = 0.02) and anxiety (p < .001). COPD patients had group differences for physical health fatigue and disease mastery (p < .01). Outcomes for depression and anxiety were generally retained at 8- and 12-month follow-up. Implementation outcomes found that despite the complexity of the targeted participants, 84% of veterans assigned to treatment received 1 or more sessions and 63% completed the treatment. The implementation strategy was viewed by providers as effective and objective ratings from audiotape reviews of bCBT sessions suggested that bCBT was delivered with high levels of adherence and skill.

Implications:
The current study lends empirical support for the use of bCBT in routine PC-MHI settings. Outcomes included changes for depression and anxiety with additional improvements in patient reported disease physical health outcomes. The study also provides evidence to support the use of a multifaceted training and support program for PC-MHI providers.

Impacts:
The current study provides evidence, methods, and a potential model for implementation of brief CBT as a key component of PC-MHI services.