Background and Significance: Randomized Controlled Trials (RTCs) have demonstrated that evidence-based psychotherapies (EBPs), particularly Cognitive Behavioral Therapy (CBT), are highly effective in treating anxiety and depression, the most common mental health disorders in primary care settings. Mental health (MH) providers in VA Community-Based-Out-Patient-Clinics (CBOCs) are often located in rural areas and isolated from educational opportunities. Almost half of Veterans now use CBOCs. Studies have shown that the quality of delivery of EBPs (fidelity) impacts clinical outcomes. This study will test a computer-assisted tool (CALM Tools for Living) that increases fidelity to CBT in treating depression and four common anxiety disorders, including PTSD. Although results of a large RCT, the CALM study, suggested that the tool contributed to fidelity to the CBT protocol, this hypothesis has not been tested. This study will test the tool in primarily rural CBOCs in VA VISN16. Objective: To modify a computer-assisted CBT tool to meet the needs of CBOC MH providers and Veterans, to evaluate the impact on providers' fidelity to the CBT model and clinical outcomes, and to assess how best to support future implementation.
Specific Aims /Hypothesis: (1) Engage CBOC MH providers in modifying the computer-assisted CBT tool such that its content is relevant and acceptable to Veterans and providers. We hypothesize that the modified tool will be acceptable to both Veterans and providers. (2) Compare MH provider fidelity to CBT and clinical outcomes among providers who used the tool and those who did not. We hypothesize that clinicians who use the tool will have a higher fidelity to CBT and clinical outcomes among patients will be superior. (3) Prepare for future implementation of the tool in the VA. Methodology: This study will use a Type III hybrid effectiveness design. Methods common to the field of Instructional Design and Technology (IDT) will be used to modify the tool. Thirty-four CBOC MH providers will be trained in CBT and randomized to use the tool or not. Both groups will receive external facilitation to encourage the full implementation of CBT into practice on the clinic level. MH providers will treat 10 patients each. Patients will be assessed at baseline, 3, 6, and 12 months. Provider fidelity to the CBT protocol will be measured, and finally, a tool kit for future implementation of the tool wil be disseminated. Impact: We expect the intervention to improve the technical quality of MH treatment in CBOCs and improve clinical outcomes among Veterans.
The VA is committed to providing high quality, evidence-based (EB) care to Veterans with mental illness, including those receiving care in CBOCs. However, broadly 'scaling up' EB treatments, such as Cognitive Behavioral Therapy (CBT), has been challenging. Most CBT programs have been designed for specialty (not primary) care and target one disorder only; CBT training alone does not assure that the therapy will be delivered with enough fidelity to be clinically effective. In this study we will (1) adapt a computer based tool to guide CBOC-based therapists and patients in CBT for depression, PTSD, GAD, PD, and SAD, (2) test the hypothesis that use of the tool will result in higher fidelity to the CBT model and, as a result, better clinical outcomes for Veterans, and (3) plan for future implementation of the tool more broadly in the VA.
