Lead/Presenter: Joseph Mignogna, VISN 17 Center Of Excellence for Research on Returning War Veterans
All Authors: Mignogna J (VISN 17 Center of Excellence for Research on Returning War Veterans; Central Texas VA Healthcare System, Texas A&M University), Finley, E (University of Texas-San Antonio Health Science Center, South Texas Veterans Healthcare System ), Post, E ( VA Central Office - Primary Care-Mental Health Integration, VA Ann Arbor, University of Michigan) Sansgiry, S (Michael E. DeBakey VA Medical Center; Baylor College of Medicine) Cully, J (Michael E. DeBakey VA Medical Center; Baylor College of Medicine) Wong, G (University of Oxford) Pierson, DM (VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Healthcare System) MacCarthy, A (VISN 17 Center of Excellence for Research on Returning War Veterans, Central Texas Veterans Healthcare System) Sanders, C (VISN 17 Center of Excellence for Research on Returning War Veterans,Central Texas Veterans Healthcare System) Kearney, L (VISN 2, VA Center for Integrated Healthcare) Wray, L (VISN 2, VA Center for Integrated Healthcare) McCarthy, J (VA Ann Arbor; University of Michigan) Pomerantz, A (VA Central Office - Primary Care-Mental Health Integration) Funderburk, J (VISN 2, VA Center for Integrated Healthcare) Benzer, JK (VISN 17 Center of Excellence for Research for Returning War Veterans, Central Texas Veterans Healthcare System, University of Texas-Dell Medical School)
Using a Realist Evaluation approach, we sought to identify how, for whom, and under what contexts integrated primary care-mental health (PC-MH) programs deliver high quality individual psychotherapy for depression.
Administrative patient data for patients newly diagnosed with depression and initiating psychotherapy were used to identify VA Medical Centers (VAMCs) delivering high or low rates of brief psychotherapy in primary care. PC-MH providers and program directors (N = 32) were recruited from 5 high performing sites (HPS) and 9 low or low/middle sites (LPS). Qualitative (i.e., individual interviews) and quantitative (i.e., administrative patient records) data were used to develop and iteratively refine theories explaining underlying causal mechanisms and contextual factors enabling success of each step in the patient pathway toward receipt of high quality psychotherapy in primary care.
HPS provided high quality psychotherapy (i.e., 3-8 psychotherapy sessions) to 57 percent of patients who only received psychotherapy in primary care, while LPS provided it to roughly half this number. Additionally, HPS had a much lower percentage of patients only receiving one psychotherapy session (i.e., 19 percent versus 51 percent, respectively). Interestingly, HPS provided a greater percentage of patients with nine or more sessions. Using qualitative data, a patient pathway was developed to identify successive targeted outcomes required for a Veteran to receive a full course of psychotherapy in primary care. As expected, contextual factors were numerous and varied across high performing sites. Causal mechanisms leading to identified outcomes of the patient pathway to high quality psychotherapy in primary care were also identified.
The reviewed study validated a realist program theory explaining PC-MH system design and psychotherapy provider decision-making processes underlying delivery of high-quality psychotherapy for depression in primary care, and the impact of contextual factors on these mechanism.
Realist Evaluation is an important methodological advancement in implementation science research that enables us to test and refine hypothesized mechanisms, and understanding in what contexts they occur. By improving the process of psychotherapy delivery in primary care, the VA has an opportunity to improve Veteran access to high quality psychotherapy and better conserve specialty mental health resources for Veterans with more intensive treatment needs.