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IIR 09-088 – HSR&D Study

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IIR 09-088
Cognitive Behavioral Therapy in Primary Care: Treating the Medically Ill
Jeffrey Cully PhD MEd
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: October 2010 - September 2014

BACKGROUND/RATIONALE:
Cognitive Behavioral Therapy (CBT) is an efficacious treatment for depression and anxiety in the non-medically ill and recent evidence suggests its efficacy for patients with comorbid health conditions. Brief CBT interventions hold the potential to be used in non-traditional mental health settings but additional research is needed to determine it's effectiveness and potential for implementation within VA primary care settings.

OBJECTIVE(S):
The specific aims of this study were two-fold. 1) To determine whether brief CBT is effective when delivered by frontline VA providers. The effectiveness aim examined whether patient-centered outcomes (depression, anxiety, and physical health) differed as a function of the intervention (brief CBT provided by VA clinicians vs. Usual Care (UC)); 2) To determine if brief CBT holds the potential to be implemented within VA primary care settings. Implementation outcomes focused on the assessment of CBT adoption and implementation (treatment fidelity) as delivered by VA Primary Care Mental Health Integration (PC-MHI) clinicians.

METHODS:
This study used a multi-site, randomized effectiveness design to assess a primary care-based brief CBT intervention for medically ill Veterans with Chronic Obstructive Pulmonary Disease (COPD) and/or Heart Failure (HF) and comorbid symptoms of depression and/or anxiety. The brief CBT intervention was tested under real-world conditions using existing Primary Care Mental Health Integration (PC-MHI) clinicians in Houston and Oklahoma City VA Medical Centers. Clinicians at each site were trained and supported in their use of brief CBT using a structured implementation approach. Veteran participants were identified and screened for eligibility, using VA databases and telephone-based assessments. A total of 302 Veterans were randomized with 180 randomized to brief CBT and 122 to usual care. A total of 19 VA clinicians were enrolled in the trial and received the implementation strategy to support their use of brief CBT.

FINDINGS/RESULTS:
Effectiveness outcomes
Intent to treat patient outcomes at 4-months (immediate post treatment) found significant group differences between treatment and usual care for depression symptoms (p=0.02), anxiety symptoms (p<.001), and COPD fatigue (p<.01) emotional functioning (p<.01) and mastery (p<.01). No significant differences were found in heart failure functioning at 4 months. Follow-up analyses indicated that significant outcomes for depression and anxiety were generally retained at 8- and 12-month follow-up (with depression symptom change falling to p=0.06 by 12 months). COPD mastery scores remained significant at 8-month follow up but all other physical health factors were no longer significant by 8- and 12-month follow-up.

Implementation outcomes
Despite the complexity and severity of the medical illness patient population, 84% of participants assigned to the treatment group received 1 or more sessions, and 63% completed the treatment (defined a priori as 4 or more sessions). The implementation strategy to support provider brief CBT use was viewed as both feasible and acceptable by frontline VA clinicians. Audit and feedback data from provider/patient sessions (and rated by expert raters) found that providers were evaluated as having "good" to "very good" adherence and skillfulness in their brief CBT use.

IMPACT:
The current study provides empirical support for the use of brief cognitive behavioral therapy (CBT) in the frontlines of VA primary care practice. Data suggest robust outcomes for depression and anxiety with some additional immediate physical health benefits. Deterioration of outcomes by 12-months suggest the need for additional follow-up care as part of the chronic nature of COPD and heart failure.

The study also provides preliminary evidence to support a multifaceted training and support program for VA healthcare providers in the primary care setting. The piloted implementation approach was viewed as feasible and acceptable to providers. More importantly, providers in the study were able to effectively deliver the brief CBT intervention as part of their usual care practices.

Finally, the study advances research in the area of blended effectiveness-implementation approaches. Additional research is needed on dissemination of brief CBT within the VA.

PUBLICATIONS:

Journal Articles

  1. Ecker AH, Johnson AL, Sansgiry S, Fletcher TL, Hundt N, Petersen NJ, Sweeney AC, Chaison AD, York-Ward KM, Kauth MR, Kunik ME, Cully JA. Brief cognitive behavioral therapy reduces suicidal ideation in veterans with chronic illnesses. General hospital psychiatry. 2019 May 1; 58:27-32.
  2. Hundt NE, Renn BN, Sansgiry S, Petersen NJ, Stanley MA, Kauth MR, Naik AD, Kunik ME, Cully JA. Predictors of response to brief CBT in patients with cardiopulmonary conditions. Health psychology : official journal of the Division of Health Psychology, American Psychological Association. 2018 Sep 1; 37(9):866-873.
  3. Renn BN, Hundt NE, Sansgiry S, Petersen NJ, Kauth MR, Kunik ME, Cully JA. Integrated Brief Cognitive Behavioral Therapy Improves Illness Intrusiveness in Veterans With Chronic Obstructive Pulmonary Disease. Annals of behavioral medicine : a publication of the Society of Behavioral Medicine. 2018 Jul 13; 52(8):686-696.
  4. Mignogna J, Martin LA, Harik J, Hundt NE, Kauth M, Naik AD, Sorocco K, Benzer J, Cully J. "I had to somehow still be flexible": exploring adaptations during implementation of brief cognitive behavioral therapy in primary care. Implementation science : IS. 2018 Jun 5; 13(1):76.
  5. Thakur ER, Sansgiry S, Petersen NJ, Stanley M, Kunik ME, Naik AD, Cully JA. Cognitive and Perceptual Factors, Not Disease Severity, Are Linked with Anxiety in COPD: Results from a Cross-Sectional Study. International Journal of Behavioral Medicine. 2018 Feb 1; 25(1):74-84.
  6. Cully JA, Stanley MA, Petersen NJ, Hundt NE, Kauth MR, Naik AD, Sorocco K, Sansgiry S, Zeno D, Kunik ME. Delivery of Brief Cognitive Behavioral Therapy for Medically Ill Patients in Primary Care: A Pragmatic Randomized Clinical Trial. Journal of general internal medicine. 2017 Sep 1; 32(9):1014-1024.
  7. Wendell J, Ratcliff CG, Price E, Petersen NJ, Dinapoli EA, Cully JA. Factors Associated With High Frequency of Suicidal Ideation in Medically Ill Veterans. Journal of psychiatric practice. 2016 Sep 1; 22(5):389-97.
  8. Hundt NE, Calleo JS, Williams W, Cully JA. Does using cognitive-behavioural therapy skills predict improvements in depression? Psychology and psychotherapy. 2016 Jun 1; 89(2):235-8.
  9. Breland JY, Hundt NE, Barrera TL, Mignogna J, Petersen NJ, Stanley MA, Cully JA. Identification of Anxiety Symptom Clusters in Patients with COPD: Implications for Assessment and Treatment. International Journal of Behavioral Medicine. 2015 Oct 1; 22(5):590-6.
  10. Hundt NE, Bensadon BA, Stanley MA, Petersen NJ, Kunik ME, Kauth MR, Cully JA. Coping mediates the relationship between disease severity and illness intrusiveness among chronically ill patients. Journal of Health Psychology. 2015 Sep 1; 20(9):1186-95.
  11. Mignogna J, Hundt NE, Kauth MR, Kunik ME, Sorocco KH, Naik AD, Stanley MA, York KM, Cully JA. Implementing brief cognitive behavioral therapy in primary care: A pilot study. Translational behavioral medicine. 2014 Jun 1; 4(2):175-83.
  12. Cully JA, Curry AD, Ryan SR, Malik A, Zeno D, Willcockson IU. Development of a computer-aided training program for brief cognitive-behavioral therapy in primary care. Academic Psychiatry : The Journal of The American Association of Directors of Psychiatric Residency Training and The Association For Academic Psychiatry. 2013 Mar 1; 37(2):120-4.
  13. Cully JA, Armento ME, Mott J, Nadorff MR, Naik AD, Stanley MA, Sorocco KH, Kunik ME, Petersen NJ, Kauth MR. Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient-randomized effectiveness-implementation design. Implementation science : IS. 2012 Jul 11; 7(1):64.
Journal Other

  1. Mignogna J, Cully J. Depression and Anxiety in Patients with COPD: A Focus on Psychological Treatments in Ambulatory Care Settings. Current respiratory medicine reviews. 2012 Apr 1; 8(2):137-144(8).
Center Products

  1. Cully J, York K, Mignogna J. Cognitive behavioral therapy in primary care mental health: Opportunities and challenges. Primary care-mental health integration education conference call. 2012 Jun 7.
Conference Presentations

  1. Mignogna J, Martin L, Harik J, Kauth M, Kunik ME, Naik AD, Cully J. Implementing Brief Psychotherapy in Integrated Primary Care: Understanding the Experiences of a Multidisciplinary Group of Clinicians. Poster session presented at: VA Psychology Leadership Conference; 2016 Jun 1; San Antonio, TX.
  2. Renn BN, Sansgiry S, Kunik ME, Cully J. Illness intrusiveness among Veterans with cardiopulmonary disease. Presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2016 Mar 31; Washington, DC.
  3. Ratcliff CG, Barrera T, Petersen NJ, Sansgiry S, Kauth M, Naik AD, Sorocco K, Cully J. Mental Health Diagnoses in the Medical Records of Patients with COPD and CHF: Who Gets Missed? Poster session presented at: American Psychosomatic Society Annual Scientific Meeting; 2016 Mar 12; Denver, CO.
  4. Martin L, Mignogna J, Mott JM, Hundt NE, Kauth M, Kunik ME, Naik AD, Cully J. Implementing Brief Cognitive Behavioral Therapy (CBT) in Primary Care: Clinicians' Experiences from the Field. Poster session presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 15; Washington, DC.
  5. Martin L, Mignogna J, Mott J, Hundt NE, Kauth M, Kunik ME, Naik AD, Cully J. Implementing Brief Cognitive Behavioral Therapy (CBT) in Primary Care: Clinicians' Experiences from the Field. Presented at: National Institutes of Health / AcademyHealth Conference on the Science of Dissemination and Implementation; 2015 Dec 14; Washington, DC.
  6. Mignogna J, Martin LA, Mott J, Cao Y, Thakur E, Kauth M, Kunik ME, Naik AD, Cully JA. Mixed-Methods Analyses of an Implementation Strategy of Brief Psychotherapy in Primary Care. Poster session presented at: VA Psychology Leadership Conference; 2015 May 19; San Antonio, TX.
  7. Cully J, Kunik ME, Naik AD, Stanley MA, Petersen NJ, Armento M, Nadorff M, Mott J, Kauth M. Implementation strategies for increasing adoption and fidelity of cognitive behavioral therapy in primary care. Poster session presented at: VA HSR&D National Meeting; 2012 Jul 18; Washington, DC.
  8. Mignogna J, Nadorff MR, Stanley MA, Sorocco KH, Kunik ME, Kauth M, Petersen NJ, Naik AD, Cully JA. Strategies for implementing cognitive behavioral therapy in the primary care setting. Poster session presented at: Society of Behavioral Medicine Annual Meeting and Scientific Sessions; 2012 Apr 11; New Orleans, LA.
  9. Cully J. Cognitive behavioral therapy (CBT) for older adults with chronic medical illnesses and psychological comorbidity. Poster session presented at: International Psychogeriatric Association Annual Congress; 2011 Sep 6; The Hague, Netherlands.


DRA: Health Systems, Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational
Keywords: Anxiety Disorders, Behavioral Therapy, Chronic disease (other & unspecified), Clinical Diagnosis and Screening, Cognitive Therapy, Depression, Primary care
MeSH Terms: none

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