4005 — Delivery of Brief Cognitive Behavioral Therapy in Primary Care: A Randomized Trial

Lead/Presenter: Jeffrey Cully, COIN - Houston
All Authors: Cully JA (Houston HSR&D COIN; Baylor College of Medicine) Stanley MA (Houston HSR&D COIN; Baylor College of Medicine) Petersen NJ (Houston HSR&D COIN; Baylor College of Medicine) Hundt NE (Houston HSR&D COIN; Baylor College of Medicine) Kauth MR (Houston HSR&D COIN; Baylor College of Medicine) Naik AD (Houston HSR&D COIN; Baylor College of Medicine) Sorocco K (Oklahoma City VAMC) Sansgiry S (Houston HSR&D COIN; Baylor College of Medicine) Kunik ME (Houston HSR&D COIN; Baylor College of Medicine)

Objectives:
Few studies have examined the practical effectiveness and implementation potential of brief psychotherapies that integrate mental and physical health. The objective of the current trial was to determine whether an integrated brief cognitive behavioral therapy (bCBT), delivered by mental health providers in primary care, would improve depression, anxiety and quality of life for medically ill veterans.

Methods:
Design: Pragmatic patient-randomized trial comparing bCBT to enhanced usual care (EUC). Participants: A total of 302 participants with heart failure and/or chronic obstructive pulmonary disease (COPD) with elevated symptoms of depression and/or anxiety were enrolled from two Veterans Health Administration primary care clinics. Intervention: bCBT was delivered to 180 participants by staff mental health providers (n = 19) in primary care. bCBT a modular, skill-based approach used in-person or telephone sessions delivered over 4 months. Participants randomized to EUC (n = 122) received a mental health assessment documented in their electronic medical record. Main Measures: Primary outcomes included depression (Patient Health Questionnaire) and anxiety (Beck Anxiety Inventory). Secondary outcomes included disease-specific health-related quality of life. Assessments occurred at baseline, posttreatment (4 months), and 8 and 12 month follow-up.

Results:
Participants received, on average, 3.9 bCBT sessions with 63.3% completing treatment (4 or more sessions). bCBT improved symptoms of depression (p = .004; effect size, d = 0.33) and anxiety (p < .001; d = 0.37) relative to EUC at posttreatment, with effects maintained at 8 and 12 months. Health-related quality of life improved posttreatment for bCBT participants with COPD but not for heart failure. Health-related quality of life outcomes were not maintained at 12 months.

Implications:
Integrated bCBT is acceptable to participants and providers, appears feasible for delivery in primary care settings, and is effective for medically ill veterans with depression and anxiety. Improvements for both depression and anxiety were modest but persistent and the impact on physical health outcomes was limited to shorter-term effects and COPD participants.

Impacts:
bCBT was effectively delivered by staff mental health providers with high rates of patient engagement and treatment completion -- indicating that bCBT is feasible and scalable for use in the primary care setting.