Veteran Status Significantly Moderates the Positive Effect of Collaborative Care Intervention for Depression versus Usual Care
Veterans may experience more treatment-resistant mental health problems and a poorer response to psychotherapy. To date, no studies have systematically compared collaborative care outcomes between Veterans treated at VA primary care clinics and civilians treated at publicly funded non-VA primary care clinics, such as Federally Qualified Health Centers (FQHCs). This study combined data from two collaborative care trials to determine whether there were significant differences in outcomes between Veterans with depression receiving collaborative care in VA community-based outpatient clinics (CBOCs) versus civilians receiving collaborative care in FQHCs. The HSR&D-funded Telemedicine-Enhanced Antidepressant Management (TEAM) trial evaluated collaborative care at CBOCs (4/03 to 9/04), while the NIMH-funded Outreach Using Telemedicine for Rural Enhanced Access in Community Health (OUTREACH) trial evaluated collaborative care at FQHCs (11/07 to 6/09). Investigators merged data from the collaborative care and enhanced usual care arms of these separate RCTs that tested similar interventions using similar evaluation methodologies. Investigators then assessed whether clinic type moderated the effect of the intervention, controlling for socio-demographics (e.g., gender, age, ethnicity, income, social support) and clinical characteristics (e.g., severity of depression, age of onset, comorbidities, prior treatment for depression, perceived barriers to care).
- Veterans randomized to collaborative care in community-based outpatient clinics (CBOCs) reported a significantly and substantially lower response rate at the 6-month follow-up compared to civilians randomized to collaborative care in FQHCs after controlling for socio-demographic and clinical variables.
- Significantly more FQHC patients compared to CBOC patients reported prior (76% vs. 66%) and current depression treatment (48% vs. 41%), and rated depression treatment as acceptable (85% vs. 80%). Overall, 19% of Veterans responded to treatment compared to 30% of civilians, and 20% of men responded to treatment compared to 29% of women.
- Before a mental health intervention is widely recommended for implementation in VA, the authors recommend that it should be tested with Veterans to identify ways to tailor it to more effectively meet the unique needs of this patient population.
- The explanatory variable reflected differences in both the patient populations and the healthcare systems, and these two effects could not be disentangled in the study analyses.
This study was partly funded by HSR&D (IIR 00-078); Dr. Fortney is part of HSR&D's Center for Innovation for Veteran-Centered and Value-Driven Care, Seattle, WA. Drs. Pyne and Hudson are with HSR&D's Center for Mental Healthcare and Outcomes Research (CeMHOR), North Little Rock, AR.
Grubbs K, Fortney J, Pyne J, Mittal D, Ray J, and Hudson, T. A Comparison of Collaborative Care Outcomes in Two Healthcare Systems: VA Clinics and Federally Qualified Health Centers. Psychiatric Services. April 1, 2018;69(4):431-37.