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BACKGROUND/RATIONALE:
Depression is the most common mental disorder in HIV infected patients. Despite the availability of efficacious treatments for depression, evidence suggests that it is under-diagnosed and under-treated in routine HIV care. To address this problem, we will adapt and implement a collaborative stepped-care model for depression treatment in HIV clinics. HI-TIDES or HIV Translating Initiatives for Depression into Effective Solutions will implement the primary care collaborative care model for depression treatment in HIV clinics using evidence-based implementation strategies.
OBJECTIVE(S):
The objectives of this proposal are to: 1) Develop and evaluate the process of adapting, implementing, and sustaining collaborative care for depression in VA HIV clinics, 2) Compare the quality of depression care and the clinical effectiveness of HI-TIDES to usual care in the HIV clinics, and 3) Evaluate the cost-effectiveness of patients assigned to HI-TIDES relative to patients assigned to usual care in HIV clinics.
METHODS:
Patients will be recruited from three HIV clinics in VISN 16: Little Rock, Atlanta, and Houston. The intervention will be randomized at the level of the patient. We expect to recruit a total of 140 intervention and 140 usual care patients. Patients in the intervention group will be supported by a depression collaborative care team that will include a depression nurse care manager, clinical pharmacist, and psychiatrist. The depression nurse care manager will evaluate depression symptom severity, antidepressant side effects, depression and HIV medication adherence every two weeks over the phone during the acute phase of treatment and will record these results in CPRS. After a 50% improvement in depression severity, the intervention subject will move into the continuation phase of treatment and the patient will be contacted every four weeks by the depression nurse case manager. A formative evaluation will occur during start-up and throughout the implementation of the intervention. A summative evaluation will document the effectiveness and cost-effectiveness of the intervention using an intent to treat analysis plan.
FINDINGS/RESULTS:
The pre-implementation phase of this study has been completed. Key informant interviews were conducted with 25 providers and 8 patients to determine what is working well and not so well about recognizing and treating depression among HIV patients in their facility. Face-to-face and telephone interviews were completed with stakeholders at each site.
The implementation phase of the study began in February 2007. Mid-recruitment key-informant formative interviews were conducted with 21 providers and 17 patients to determine adjustments needed in our implementation strategy prior to completing subject recruitment. The intervention phase of the study is in progress at all 3 sites. To date, a total of 204 subjects have been enrolled.
Major activities completed in the last 12 months include completion of mid-recruitment key informant interviews, Evidence-Based Quality Improvement (EBQI) meetings at each site, and enrollment of subjects.
IMPACT:
The proposed study is highly relevant to the VA and the veterans it serves for many reasons. First, the majority of VA patients with HIV are not seen in the primary care clinics and therefore will not benefit from VHA's efforts in primary care settings to improve depression identification and treatment. Second, in addition to the negative outcomes of depression generally, depression in HIV patients is associated with additional negative outcomes including accelerated HIV disease progression, decreased immune system functioning, and premature death. Third, directly moving collaborative depression care from primary care clinics to HIV clinics is likely to fail for several reasons including the comorbidities associated with depressed HIV patient and the potential for drug-drug interactions. The proposed project will address these gaps and provide effectiveness and cost-effectiveness analyses to inform decisions about larger scale implementation of the HI-TIDES intervention.
PUBLICATIONS:
None at this time.
DRA:
Chronic Diseases, Mental Illness, Special (Underserved, High Risk) Populations
DRE:
Treatment, Quality of Care
Keywords:
HIV/AIDS, Implementation
MeSH Terms:
none
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