Comorbid depression has been consistently linked to worse outcomes for patients in substance abuse treatment programs. Practice guidelines recommend pharmacotherapy for comorbid depression if symptoms persist after a 4-week "wash-out" period for detoxification (e.g., Veterans Health Administration; American Psychiatric Association). Medications may be considered earlier if a patient has current symptoms and a history of major depressive disorder (MDD) during periods of sobriety. Current efficacy data suggest that antidepressant medication can improve both depression and substance use outcomes among comorbid patients Guideline-concordant use of antidepressant medication for persons with comorbid substance use and depressive disorders, however, is not routine in many VA substance abuse treatment settings.
This study seeks to develop, implement, and test an organizational intervention in VA substance abuse treatment settings to establish guideline-concordant treatment of comorbid depression. The intervention will assist "intervention" programs in their own implementation of a guidelines-based treatment algorithm to improve the recognition of depression and initiation of pharmacotherapy.
Substance abuse treatment programs in the South Central VISN were matched on program characteristics and current depression management practices (n = 4), and "intervention" sites were randomly chosen from each pair. Phase 1 (now completed) of the study analyzed the barriers and facilitators to translation of depression management in participating facilities, and used these data to inform the development of the translation intervention, its implementation tools, and the depression algorithm. The translation intervention adopted in this plan was based on the PRECEDE model of organizational behavior change and included provider education, use of local champions, feedback of screening data, and patient education/activation. The depression management algorithm and intervention was developed with input from programs staff and an Advisory Panel of depression management and translation experts. Phase 2 of the study implemented and tested the intervention. The evaluation in examining program- and provider-level outcomes. Program-level outcomes include feasibility, extent of adoption of the algorithm, and provider/organizational attitudes and beliefs about the intervention's design and effectiveness. Patient-level outcomes include depressive symptoms, substance use outcomes, medication adherence, quality of life, and services use.
Data collection is complete for Phase 1 of the study. Qualitative interviews with veterans found comorbid individuals in substance use treatment programs to exhibit a considerable lack of understanding about their depressive disorder. They reported wanting more information about their condition, its causes, and treatments available. As well, while many have been on medication at some point, medication adherence was often reported as a barrier to treatment success. A common recommendation offered for programs is more opportunities for "talk therapies" and group interactions with other persons with depression and substance use disorders. The intervention programs began implementing the depression intervention in spring of 2005. The implementation phase is complete at those sites, with one site implementing fully with little difficulty, and the second site achieving only partial implementation, and with difficulty. Organizational factors at the root of implementation success are being explored now (process evaluation). Enrollment of veterans began in spring of 2005 at the two intervention sites and one of the comparison sites. IRB delays moved the start date of the 2nd comparison site to September 2005. Hurricane Katrina caused the closure of the two comparison site (Gulf Coast), and enrollment was cut short at those sites. Enrollment is complete (although at a lower number due to loss of a local PI) at one intervention site and near complete at the second (full enrollment expected). No patient-level data analyses have been conducted at this time.
Impact is minimal at this time.
- Curran GM, Mukherjee S, Allee E, Owen RR. A process for developing an implementation intervention: QUERI Series. Implementation science : IS. 2008 Mar 19; 3:17.
- Curran GM, Kirchner JE, Worley M, Rookey C, Booth BM. Depressive symptomatology and early attrition from intensive outpatient substance use treatment. The journal of behavioral health services & research. 2002 May 1; 29(2):138-43.