In spite of the impact on veteran's health status and treatment cost, depression is under-diagnosed and under-treated. The goal of this study is to learn how to implement a previously tested, effective collaborative care model for improving the quality of depression care across multiple Veterans Integrated Service Networks (VISNs). To achieve this goal, we are conducting a randomized controlled trial of evidence-based quality improvement (EBQI), a dissemination method that relies on expert design and local implementation of evidence-based practice interventions. We hypothesize that EBQI will result in increased rates of assessment and appropriate management of depression. Results will be useful in designing realistic chronic care programs and performance measures for continuing care improvement.
Our primary objective is to evaluate whether collaborative care EBQI results in increased rates of assessment and appropriate management of depression and decreased depressive symptomatology for veterans. Our secondary objective is to evaluate the effect of EBQI on organizational outcomes.
Three VISNs, 10, 16 and 23, are participating. Three primary care clinics within each VISN are randomized, two to the intervention and one to usual care, for a total of nine study sites. In the intervention clinics, VA leadership, assisted by study staff, tailor and implement a depression care program for patient assessment, patient self-management support, provider education, primary and mental health collaboration, and care management. The usual care clinics participate only in the evaluation. Patient recruitment is through a telephone interview. Patients who are at risk for major depression are recruited, 67 from each site. Patient outcomes including depression symptom severity on the PHQ-9 and the VA SF-12 have been assessed by telephone at six months post enrollment. Other outcome variables are adequacy of antidepressant trials, psychotherapy and specialty care visits, and treatment adherence. A utilization and cost analysis will be conducted. VISN and VAMC leadership are surveyed to assess organizational outcomes. Data is being collected through VA administrative databases, patient and staff interviews, and study records. Power calculations and data analysis planning reflect the clustered sample design.
Initial analysis of VISN and VAMC leadership surveys suggest that organizational support at all levels; central, VISN, VAMC, clinic, and provider is necessary to implement collaborative care for depression and that specifics of implementation need to be individualized for the specific clinic environment. Initial analysis of baseline survey results show that patients who have a history of comanagement by primary care and mental health specialty clinics have more severe psychological symptomatology than those not referred to mental health.
Initial VISN and VAMC leadership surveys documented facilitating factors and barriers that helped to design additional MH QUERI studies of implementation of collaborative care for depression. A paper addressing aspects of patient safety in collaborative care telephone interventions with patients who present with suicidality risk has been published in an AHRQ compendium. A paper presenting issues in forming and sustaining primary care-mental health collaboration has been accepted. Expert panel, provider education and informatics papers are in preparation as are papers on the treatment outcome, the impact of co-occurring PTSD on depression treatment and influence of social support and patient expectations. This and the related projects have formed the basis for articles by the investigators on collaborative care for depression in Practice Matters, the QUERI Quarterly and the SGIM Forum and presentations to VA HSR&D, MIRECC, AHRQ, Academy Health and other professional organizations.
External Links for this Project
- Fortney JC, Steffick DE, Burgess JF, Maciejewski ML, Petersen LA. Are primary care services a substitute or complement for specialty and inpatient services? Health services research. 2005 Oct 1; 40(5 Pt 1):1422-42. [view]
- Kanter JW, Epler AJ, Chaney EF, Liu CF, Heagerty P, Lin P, Felker B, Hedrick SC. Comparison of 3 Depression Screening Methods and Provider Referral in a Veterans Affairs Primary Care Clinic. Primary care companion to the Journal of clinical psychiatry. 2003 Dec 1; 5(6):245-250. [view]
- Felker BL, Chaney E, Rubenstein LV, Bonner LM, Yano EM, Parker LE, Worley LL, Sherman SE, Ober S. Developing effective collaboration between primary care and mental health providers. Primary care companion to the Journal of clinical psychiatry. 2006 Jan 1; 8(1):12-6. [view]
- Liu CF, Bolkan C, Chan D, Yano EM, Rubenstein LV, Chaney EF. Dual use of VA and non-VA services among primary care patients with depression. Journal of general internal medicine. 2009 Mar 1; 24(3):305-11. [view]
- Bolkan CR, Bonner LM, Campbell DG, Lanto A, Zivin K, Chaney E, Rubenstein LV. Family involvement, medication adherence, and depression outcomes among patients in veterans affairs primary care. Psychiatric services (Washington, D.C.). 2013 May 1; 64(5):472-8. [view]
- Bonner LM, Lanto AB, Bolkan C, Watson GS, Campbell DG, Chaney EF, Zivin K, Rubenstein LV. Help-seeking from clergy and spiritual counselors among veterans with depression and PTSD in primary care. Journal of Religion and Health. 2013 Sep 1; 52(3):707-18. [view]
- Chaney E, Rabuck LG, Uman J, Mittman DC, Simons C, Simon BF, Ritchie M, Cody M, Rubenstein LV. Human subjects protection issues in QUERI implementation research: QUERI Series. Implementation science : IS. 2008 Feb 15; 3:10. [view]
- Chaney EF, Rubenstein LV, Liu CF, Yano EM, Bolkan C, Lee M, Simon B, Lanto A, Felker B, Uman J. Implementing collaborative care for depression treatment in primary care: a cluster randomized evaluation of a quality improvement practice redesign. Implementation science : IS. 2011 Oct 27; 6:121. [view]
- Felker BL, Barnes RF, Greenberg DM, Chaney EF, Shores MM, Gillespie-Gateley L, Buike MK, Morton CE. Preliminary outcomes from an integrated mental health primary care team. Psychiatric services (Washington, D.C.). 2004 Apr 1; 55(4):442-4. [view]
- Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. Prevalence of depression-PTSD comorbidity: implications for clinical practice guidelines and primary care-based interventions. Journal of general internal medicine. 2007 Jun 1; 22(6):711-8. [view]
- Zivin K, Campbell DG, Lanto AB, Chaney EF, Bolkan C, Bonner LM, Miller EM, Valenstein M, Waltz TJ, Rubenstein LV. Relationships between mood and employment over time among depressed VA primary care patients. General hospital psychiatry. 2012 Sep 1; 34(5):468-77. [view]
- Waltz TJ, Campbell DG, Kirchner JE, Lombardero A, Bolkan C, Zivin K, Lanto AB, Chaney EF, Rubenstein LV. Veterans with depression in primary care: provider preferences, matching, and care satisfaction. Families, systems & health : the journal of collaborative family healthcare. 2014 Dec 1; 32(4):367-77. [view]
- Davis TD, Campbell DG, Bonner LM, Bolkan CR, Lanto A, Chaney EF, Waltz T, Zivin K, Yano EM, Rubenstein LV. Women Veterans with Depression in Veterans Health Administration Primary Care: An Assessment of Needs and Preferences. Women's health issues : official publication of the Jacobs Institute of Women's Health. 2016 Nov 1; 26(6):656-666. [view]
- Bonner L, Felker B, Chaney E, Vollen K, Berry K, Revay B, Simon B, Kofoed L, Ober S, Worley L, Fotiades J, Sherman S. Suicide risk response: enhancing patient safety through development of effective institutional policies. In: Advances in Patient Safety: From Research to Implementation [electronic compendium] Volume 3. Agency for Healthcare Research and Quality; 2005 Feb 1. 501-519 p. Report No.: 3. [view]
- Bolkan CR, Chaney EF, Uman J, Rubenstein LV, Yano EM. A Comparison of Perceptions of Primary Care Provider Behavior among Veterans by Age. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
- Simon B, Mittman D, Bonner L, Ritchie MJ, Oken C, Simons C, Chaney E. Confidentiality & Privacy Risks in Adverse Event Reporting for HSR&D Studies. Paper presented at: VA HSR&D National Meeting; 2004 Mar 10; Washington, DC. [view]
- Campbell DG, Felker BL, Liu CF, Yano EM, Kirchner JE, Chan D, Rubenstein LV, Chaney EF. Depression–PTSD Comorbidity: Implications for interventions in primary care. Paper presented at: University of Montana College of Health Professions and Biomedical Sciences School of Public and Community Health Sciences Annual Orientation; 2008 Aug 29; Missoula, MT. [view]
- Chaney EF, Simon B, Bonner L, Simons C, Ober S, Rubenstein LV, Cody M. Ensuring Patient Safety and Confidentiality in Multi-Site Quality Improvement Research: A Proactive Partnership Approach to Risk Management. Presented at: VA HSR&D National Meeting; 2009 Feb 12; Washington, DC. [view]
- Chaney EF, Rubenstein LV, Yano EM, Liu CF, Bolkan CR. Evaluating Implementation of Best Practices for Depression Care: 18 Month Results. Poster session presented at: VA HSR&D National Meeting; 2008 Feb 13; Baltimore, MD. [view]
- Campbell DG, Chaney EF, Yano EM, Simon BF, Rubenstein LV, Bonner LM, Liu CF, Simon A. Expectations for Mood Improvement: Possible Implications for Primary Care Interventions. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
- Yano E, Chaney EF, Simon B, Bonner L, Lanto AB, Campbell DG, Rubenstein LV. Health and Health Care Needs of Depressed Patients Detected in Primary Care. Paper presented at: Society of General Internal Medicine Annual Meeting; 2005 Apr 1; New Orleans, LA. [view]
- Campbell D, Bonner LM, Bolkan CR, Chaney EF, Rubenstein LV, Sherman S, Felker B. Implementation Research and Suicide Risk: Qualitative Analysis of an Assessment Process for Suicide Risk in a Sample of Depressed Veterans. Paper presented at: VA HSR&D National Meeting; 2008 Feb 14; Baltimore, MD. [view]
- Fickel JJ, Parker LE, Yano EM, Kirchner JE, Ritchie MJ. Improving Depression Care Through Primary Care-Mental Health Collaboration. Paper presented at: AcademyHealth Annual Research Meeting; 2004 Jun 6; San Diego, CA. [view]
- Rubenstein LV, Chaney E, Yano EM, Petzel R. Making the researcher/clinical leader partnership real: The depression intervention design panel. Paper presented at: Agency for Healthcare Research and Quality Translating Research Into Practice and Policy Annual Meeting; 2004 Jul 13; Washington, DC. [view]
- Chaney E, Rubenstein L, Yano e, Liu CF, Kirchner JE, Bonner L, Felker B, Vivell S, Simon B, Lanto A, Campbell D. Randomized trial of implementation of collaborative care for depression in primary care: WAVES. Poster session presented at: Scientific Basis of Health Services International Annual Conference; 2005 Sep 18; Montréal, Canada. [view]
- Bonner LM, Chaney EF, Lanto A, Yano E, Simon B, Rubenstein LV, Simon A. Social Support Resources and Preferences in Depressed Veterans in Primary Care. Paper presented at: VA HSR&D National Meeting; 2005 Feb 1; Baltimore, MD. [view]
- Mittman D, Ritchie MJ, Simon B, Chaney E, Bonner L, Simons C, Oken C. Translation Research Barriers: Adverse Events Reporting. Paper presented at: VA QUERI National Meeting; 2003 Dec 10; Washington, DC. [view]
Mental, Cognitive and Behavioral Disorders, Health Systems
Depression, Primary care, Quality assurance, improvement