VA's Primary Care-Mental Health Integration (PC-MHI) initiative focused initially on depression as a single disease. Though the initiative offered a path toward improved depression care, VA needed to enhance its ability to fully address the complex and often acute needs of depressed Veterans, who are more likely than other depressed populations to experience significant medical, psychiatric and social conditions that reduce depression treatment effectiveness. While evidence exists regarding the impact of these medical, psychiatric and social conditions on care, very little of it addresses their co-management in the context of VA PC-MHI treatment protocols.
Drawing upon findings from a longitudinal VA depression care study, WAVES (Well-being Among Veterans Enhancement Study), the current project leveraged the implicit/explicit knowledge of an Expert Panel (EP) composed of VA organizational, clinical and science leaders to: (1) develop a foundation for PC-MHI guidelines that support decision-making for depressed Veterans who experience clinically significant co-occurring conditions; and (2) evaluate the importance and feasibility of proposed strategies to redesign and improve depression management through targeting these co-occurring medical, psychiatric and social conditions.
This project was conducted in four stages. In the first stage, we identified 10 WAVES products (manuscripts and works-in-progress) and related works from the literature that examined contextual factors and common co-occurring conditions among depressed Veterans in PC. Working from these products, we derived 48 strategies for enhanced clinical management of depression across nine clinically significant areas of focus. These strategies formed the content of the Collaborative Depression Care Redesign Preferences Questionnaire (CDCRPQ), a survey that asked experts to rate the 'importance' and 'feasibility' of implementing each management strategy as well as the overall importance of each focus area. In stage two, we assembled an EP of VA depression care stakeholders. The EP comprised PC and mental health leads, a depression care manager, an implementation specialist, a chaplain, a social worker, experts in women's health and racial/ethnic minority health disparities, as well as substance abuse, PTSD, employment, and smoking experts. We provided panelists with a packet of the 10 WAVES products and related works in preparation for their task of completing the CDCRPQ online. At the start of stage three, we analyzed the EP's CDCRPQ responses and summarized the results. These results then served as stimuli for discussion during a 2-hour online EP meeting. For the project's final stage, we developed and administered the CDCRPQ-2, a follow-up EP survey that included 22 of the depression management strategies across eight focus areas. The chosen strategies were those rated most important by the panelists on the original survey. These were refined to reflect the EP discussion and commentary. The nine original areas of focus were reduced to eight on the panelists' recommendation to fold smoking cessation into illness complexity. EP participants used the CDCRPQ-2 to rate the importance of the 22 refined clinical management strategies for depression and to re-rate the overall importance of the existing eight clinical areas.
The final group of eight clinically significant areas of focus for depression care redesign included patients' preferences for clergy involvement in care or spiritual support, stigma, minority patients' needs and preferences, women's needs and preferences, patient employment, patients' general care preferences and satisfaction, family involvement in care and social support, and patients' illness complexity and psychiatric comorbidity. On the pre- and post-EP meeting questionnaires, (CDCRPQ and CDCRPQ-2, respectively), panelists assigned ratings indicating all areas were at least somewhat important for redesign efforts [i.e., mean ratings were all above a "5" on the 7-point importance rating scale (1='low'; 7='high')]. Following the EP meeting, we defined the most important areas as having ratings at or above a '6'. The three top-rated areas in descending order included patients' care preferences and satisfaction, family involvement in care and social support, and patients' employment status.
Several enhanced clinical management strategies were identified across the focus areas as particularly important for depression care. Regarding patients' care preferences and satisfaction, the most highly rated strategy was for care managers to educate patients, either directly or through an expert consultant, about evidence-based treatments and provider types, and how the patient might access their preferred treatments when they are available. The top social support strategy urges care managers to help patients identify appropriate VA and local social support resources and activities (e.g., support groups, family psychoeducation opportunities, volunteer work, or activities with friends) and to monitor these activities. Finally, the top employment strategy calls for care manager education. The experts indicated that care managers need to know that employment loss or underemployment is clinically important among patients with depression.
Expert panelists identified a number of concerns regarding implementation of the strategies that were relevant across multiple focus areas. Cross-cutting issues included the appropriate scope and targets of PC-based depression care, staffing for the management strategies (e.g., who should be responsible for what duties?), competing demands and limited clinical resources for already busy PC providers, a need for clear care management protocols for assessment and intervention, managing health literacy variability among patients, and accommodating patients' preferences for modes of care (e.g., psychotherapy) that differ in availability across VA facilities.
This project provides direction for improving PC-MHI depression treatment protocols to address multiple psychiatric and social conditions concurrently. The present project employed an Expert Panel approach to identify and then refine the most promising strategies for patient-centered depression care management. Improved management of depression will result in improved well-being for Veterans with depression in PC and will have wide-reaching positive effects on Veterans' health.
- 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.
- Campbell DG, Chaney EF, Simon BF, Simon A, Lombardero A, Bolkan CR, Bonner LM, Zivin K, Waltz TJ, Rubenstein LV, Davis T. Customizing VA depression care approaches in response to Veterans’ needs and preferences: A novel approach. Poster session presented at: VA HSR&D / QUERI National Meeting; 2015 Jul 8; Philadelphia, PA.
- Chang ET, Post EP, Williams JW, Mehta P, Rubenstein LV. Integrating Mental Health into Patient-Centered Medical Homes (PCMH): Recommendations from a VA expert panel. Paper presented at: Society of General Internal Medicine Annual Meeting; 2015 Apr 24; Toronto, Canada.