|
BACKGROUND/RATIONALE:
More than 20% of patients in primary care have depressive disorders. Although primary care is the principal venue for treating depression, data suggest few patients receive adequate treatment for depression in primary care and more than half still meet criteria for major depressive disorder (MDD) after one year. These outcomes are even worse in rural areas where availability of mental health providers is limited and distances often preclude regularly scheduled follow-up appointments required by depression care guidelines.
Many studies have examined methods of improving depression outcomes in primary care. Interventions focused on improving physician knowledge or treatment have not generally been effective. Telephone-administered case management programs have demonstrated some improvement in outcomes through increasing patient adherence to pharmacotherapy. However, up to half of these patients still fail to show significant reductions in depressive symptoms. Patients who do poorly are more likely to have increased levels of stress and social dysfunction (e.g. conflictual relationships, low social support). Cognitive behavioral therapy (CBT), a behavioral treatment that teaches methods of coping with stress, distress, and social difficulties, has demonstrated particularly good results for depression. CBT delivered within primary care has been shown result in substantial improvements in 60-72% of depressed patients. However, CBT is largely unavailable to patients in rural areas both because of the lack of services and/or the distances patients must travel to obtain those services. This creates inequities in available care based on geography. We have developed a telephone administered CBT (T-CBT). We have shown that T-CBT can produce substantial improvements in depression. T-CBT can also overcome barriers to treatment found in rural areas.
OBJECTIVE(S):
The primary objective of this study is to evaluate the efficacy of 16-sessions of T-CBT in a rural veteran population.
METHODS:
Recruiting from 3 VISN 12 and 3 VISN 21 Community Based Outpatient Clinics CBOCs serving primarily rural veterans, 154 primary care patients diagnosed with MDD, will be randomized to with T-CBT or to a treatment as usual (TAU) control group. T-CBT will consist of 12 weekly sessions, followed by 4 more sessions at increasing intervals, designed to promote maintenance of gains. Primary outcomes will include diagnosis of major depressive disorder, as well as assessments of objective and subjective severity of depressive symptoms at post-treatment. Outcomes will be assessed at baseline, 12-weeks, post-treatment (20-weeks) and 6-months after cessation of treatment.
FINDINGS/RESULTS:
There are no results to report at this time.
IMPACT:
This study is highly significant to the VA and the veterans it serves for many reasons. Psychotherapy is available to veterans in VISN 21 and VISN 12 who can come to hospital-based clinics, but is largely unavailable to patients served by rural CBOCs, including those with whom we propose to work.
Validated telephone delivered treatments for depression could remove barriers to access resulting from geographic distance from mental health services, lack of specialized mental health services at local clinics, or other circumstances that impede access to care such as disability that interferes with regular attendance of appointments.
If the hypotheses are supported, VA will have a manualized telephone-administered treatment for depression along with a companion workbook that has been validated as a successful treatment for depression in primary care. This is of particular importance as VA is currently developing tele-mental health guidelines for the delivery of care among hospitals and between hospitals and Community Based Outpatient Clinics (CBOCs).
PUBLICATIONS:
None at this time.
DRA:
Health Services and Systems, Mental Illness, Special (Underserved, High Risk) Populations
DRE:
Treatment, Quality of Care
Keywords:
Depression, Rural, Telemedicine
MeSH Terms:
none
|
