Veterans' receipt of psychotherapy is limited in the VA. Mental health services are offered in primary care, however, providers lack guidance about how, and for whom, to provide psychotherapy. Veterans identified with a depressive disorder in primary care are commonly referred to specialty mental health services, however, some Primary Care-Mental Health Integration (PC-MHI) programs can effectively deliver high-quality psychotherapy in the primary care setting. Without identifying and disseminating existing best practices for delivering high-quality psychotherapy practices in primary care, inadequate psychotherapy practices will likely continue, with best practices confined to local PC-MHI programs.
This study sought to explain how, for whom, and under what circumstances VA Medical Centers (VAMCs) PC-MHI programs are best able to effectively deliver individual psychotherapy for depression in primary care consistent with evidence-based recommendations (i.e., 3-8 sessions). Specifically, this study aimed to determine PC-MHI system design and psychotherapy provider decision-making processes that underlie the effective delivery of high-quality psychotherapy (3-8 sessions) for depression, and the impact of contextual factors on these processes.
Using maximum variation sampling to highlight similarities and differences between high and low performing PC-MHI programs at delivering high-quality psychotherapy, we compared PC-MHI program design features (e.g., use of open access clinic slots, colocation of offices in primary care) and provider decision-making processes used to guide psychotherapy delivery in primary care. VA administrative patient data was used to identify and recruit PC-MHI psychotherapy program directors and psychotherapy providers (N=33) from a purposeful sample of 5 high and 9 lower performing VAMC PC-MHI programs at delivering psychotherapy. Data collection occurred over 2 study phases and included qualitative (individual interviews of PC-MHI directors and psychotherapy providers) and quantitative (i.e., administrative patient records) data. Realist Evaluation (RE), an explanatory evaluation framework for explaining how a program or intervention works, guided the investigative process and focused data collection and analysis on testing and iteratively refine an initial hypothesized program theory. The program theory provides an overarching theory explaining the underlying enabling/inhibiting mechanisms and associated conditions (i.e. contextual factors) in the delivery of evidence-based psychotherapy for depression in primary care. With the goal of data saturation, splitting the study into 2 phases allowed us sufficient time and space to analyze data during Phase 1 so that efforts in Phase 2 were used to fill 'gaps' identified in the data. Across study phases, we used cross-case comparisons of data collected within and between each PC-MHI program to test and continually refine the program theory. Using the RE framework, data analyses sought to identify mechanisms associated with process outcomes leading to the delivery of 3-8 sessions of psychotherapy in primary care, and contextual factors that enabled the firing of these mechanisms. We sought to identify these Context-Mechanism=Outcome configurations consistently reported across high performing VAMCs but not low performing VAMCs.
A patient pathway was developed by the study team to identify successive targeted outcomes required for a Veteran to receive a full course of psychotherapy in primary care. Study analyses aimed to identify mechanisms leading to each outcome and relevant contextual influences.
The first step in the patient pathway is a Veteran is recognized with Depression during a medical primary care visit. A Veteran is more likely to be identified with depression if he directly brings up relevant concerns with the PC provider and/or is more comfortable in truthfully responding to inquisitions by the PC provider and staff during formal or informal screening for depression. Contextual influences include the PC providers familiarity and comfort in discussing depression and use of direct marketing about PC-MHI services to Veterans in the PC waiting room.
Once recognized, the next outcome is that the PC provider refers the Veteran to a PC-MHI provider. This referral is more likely to happen through a warm-hand off of the Veteran to a PCMHI provider. Influences of this occurring is the strength of the working relationship between the PC and PC-MHI providers, proximity of provider offices to primary care offices, as well as, the availability of PC-MHI providers for PC doctors. The cohesion and coordination of PC-MHI teams impacts the readiness of PC-MHI providers for warm handoffs.
During the intake interview, the Veteran will next need a referral from the PC-MHI provider to individual psychotherapy in primary care. Contextual influences impacting the shared decision making process between the provider and Veteran leading to this outcome include a provider's availability to regularly schedule psychotherapy sessions given competing clinical responsibilities. Higher performing programs report being less restrictive regarding who they view as appropriate for treatment in primary care for depression. Additionally, PC-MHI providers express hesitation about referring Veterans to specialty mental health services out of concern the referral would be judged to be inappropriate.
For the final step, a veteran initiates and subsequently engages in 3-8 sessions of psychotherapy. Some notable contextual factors thought to influence a Veteran's decision to participate in psychotherapy include the provider's use of Motivational Interviewing techniques, increased frequency of initial psychotherapy sessions, and the provider's flexibility in scheduling and ability to deliver psychotherapy by phone if requested by a Veteran. Also, the provider's skillfulness at developing a strong therapeutic relationship is another contextual factor impacting a Veterans receipt of a full dose of psychotherapy.
By understanding the system design and provider decision-making processes that underlie the effective delivery of high-quality psychotherapy for depression in primary care, organizational interventions can be developed to improve the delivery of high quality psychotherapy in integrated primary care settings. By improving delivery of psychotherapy in primary care, medical centers could better conserve specialty mental health resources for Veterans with more intensive treatment needs. Findings from the current study are being used to develop an organizational-focused intervention to improve brief psychotherapy delivery in primary care.
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Grant Number: I21HX002244-01A1
None at this time.