Studies on the TIDES model of coordinating depression treatment within the primary care setting demonstrate that it can significantly improve quality of care and improve outcomes. However, few Veterans receive guideline-concordant care, and many remain significantly depressed after a year with the program. There is reason to expect that an appropriate, efficient, and well-crafted family/caregiver intervention could augment TIDES's effectiveness.
The main objective of this pilot study was to test the feasibility of a 4-session, psychoeducational, family/caregiver intervention designed to improve the effectiveness of TIDES. The specific study aims were: 1) to examine the feasibility of the family intervention for Veterans and their family members in terms of interest and participation, and 2) to collect preliminary data regarding changes in depressive symptoms, medication compliance, family relationships (satisfaction, support, criticism, conflict), behavioral activation, and knowledge about depression. It was hypothesized that participation in the family intervention would decrease depressive symptoms, improve medication compliance and family relationships, and increase behavioral activation and knowledge about depression.
The pilot study utilized a one-group, pre-post design in which study participants (N = 29 Veteran/family member dyads) serve as their own controls. All Veterans who were admitted into the TIDES program at the Long Beach and Loma Linda VAs and had a PHQ-9 score greater than 10 were eligible to participate in the study. Participating family members received a depression education handout in the mail and 4 telephone sessions of psychoeducation regarding depression. The telephone sessions focused on general education about depression, and the importance of medication, symptom monitoring, behavioral activation, and social support. Veterans and their family members were assessed at baseline and following the intervention (approximately 3 months later).
Feasibility data collected included the percentage of depressed Veterans in TIDES who were willing to allow a family member to participate in their treatment, the percentage of family members who were willing to participate in the intervention, and the number of treatment sessions in which family members participated. The Beck Depression Inventory (BDI) was used to measure depression symptom severity. Medication compliance was assessed by asking Veterans how many days in the past 30 they had missed taking their medication. Family relationships were assessed using the McMaster Family Assessment Device (FAD) and the Niv Family Support and Conflict Questionnaire. The activation scale of the Behavioral Activation for Depression Scale (BADS) and the Knowledge Test of Depression were also completed. To assess satisfaction with and perceptions of treatment, family members completed program surveys at follow-up. Additionally, data was collected from Depression Care Managers (DCMs) regarding the strengths and weaknesses of the intervention as well as barriers and facilitators to implementation of the program.
Of the 136 Veterans who were offered the family program, 50 (37%) agreed to have a family member involved in their treatment. The most common reasons given for not wanting family involved were lack of family contact, burden to family members, and privacy issues. Some veterans expressed an interest in online education materials for their family members rather than direct contact with their clinicians. Of the 50 family members contacted, 42 (84%) agreed to participate in the family program. The remaining 8 said they weren't interested or didn't have time. Of the 42 who were interested, only 29 (69%) were enrolled in the research study. The primary obstacle to enrollment was that clinicians did not have the capacity to take on any more families. Treatment utilization data is available for 22 family members as 7 family members are still receiving the intervention. Of these 22 family members, 2 didn't engage in treatment at all, 2 completed only 1 session, and 18 completed all 4 sessions.
Preliminary outcome data are available for 17 families (3 families withdrew from the study early on and 9 families are currently enrolled in the study and don't have follow-up data yet). Analyses indicate a trend for improvement in overall depression severity as measured by the BDI (t = 2.04; p = .06). Veterans showed significant improvement in behavioral activation from baseline to follow-up (t = 2.95; p < .01). There were no significant changes in veterans' or family members' family functioning (satisfaction, support, criticism, conflict), knowledge about depression, or medication compliance.
Family members found the depression education and direct contact with the DCM most helpful. They reported feeling very supported by the VA. Examples include: "The connection and sense of having a support team in place was so comforting," and "I really hope that this whole thing continues and helps other families because it was such a phenomenal experience." Family members who've completed the study could not identify weaknesses to the program. DCMs also found the program really helpful and felt good about doing it. They did, however, identify significant barriers to implementation. Their biggest barrier was lack of time to do the program with all interested Veterans and their family members. In situation where DCMs lacked the capacity to take on new families, they sent the education handout to family members, but did not provide the intervention. DCMs also identified accents/language as a significant barrier to conducting a phone-based intervention.
Preliminary data analyses indicate that the family intervention could augment TIDES's effectiveness in improving depressive symptoms primarily by boosting behavioral activation. The program can also provide the connection to the VA that so many family members desire. However, lack of staff time to deliver the intervention to all interested parties is a considerable obstacle to implementation. Delivering the intervention via the internet may help alleviate staff burden. It would also provide families with the necessary education while addressing the privacy concerns that many Veterans expressed.
None at this time.
Mental, Cognitive and Behavioral Disorders
Treatment - Observational