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RCD 05-288 – HSR Study

RCD 05-288
Mental Health Engagement for Veterans with Congestive Heart Failure
Jeffrey Cully, PhD MEd
Michael E. DeBakey VA Medical Center, Houston, TX
Houston, TX
Funding Period: October 2006 - September 2010
Medically ill patients are at increased risk of having a mental health condition, yet these patients consistently under utilize mental health services, causing added burden on patients and health care systems. Improved recognition and access to mental health care is a priority for the VA and the entire U.S. healthcare system as addressed by the President's New Freedom Commission on Mental Health, which outlines the need for greater patient mental health knowledge and mental health care that is patient driven. Patient-level factors, including beliefs, attitudes, preferences, and psychological traits (e.g., coping styles), represent facilitators and barriers critical to patients' willingness and ability to obtain mental health care. Due to the complex interplay of somatic and psychiatric symptoms for medically ill patients with depression and/or anxiety, efforts that attempt to identify and overcome patient-level barriers have the potential to increase the number of patients obtaining care for their mental health difficulties.
The PI for this CDA-2 is now completing an HSR&D (multisite trial examining the effectiveness of cognitive behavioral therapy for medically ill patients in the primary care setting. The abstract for this project is as follows:

Patients facing chronic medical conditions are at increased risk for depression and anxiety. The associations between depression and anxiety and poor patient outcomes are clear and dramatic. Unfortunately, despite this prevalence and impact, few medically ill patients receive mental health treatment and there continues to be a dearth of information related to the use of non-medication mental health treatments such as CBT in primary care settings. To set the stage for future CBT programs within VA, additional research is needed to document the real-world effectiveness of this treatment approach.

The assembled research team seeks to examine the effectiveness of CBT within VA primary care settings using existing VA providers as study clinicians. We hypothesize that medically ill veterans receiving CBT from primary care mental health clinicians will show greater improvement in depressive / anxious symptoms and physical disease outcomes relative to a usual care (UC) control arm at post-treatment and 8- and 12-month follow-up. Secondary aims will assess patient treatment adherence and therapist CBT competence. Exploratory aims will examine the cost effectiveness of the intervention, assess stakeholder perceptions, and longer-term intervention application "post-study".

The present 4-year investigation will focus on the effectiveness of CBT for complex and chronically ill veterans using a randomized effectiveness study design. Medically ill veterans, defined as patients with chronic heart or lung disease, with comorbid symptoms of depression and/or anxiety will be recruited. Provision of CBT will occur through the VISN 16 mental health in primary care initiative at 2 hospitals (Houston and Oklahoma City). Eligible patients will be randomized to either the CBT intervention or to UC. CBT providers will include nurses, social workers, counselors and psychologists who are currently providing mental health care as part of the VA's Mental Health in Primary Care Initiative. The CBT treatment will consist of a manualized therapy developed for our prior HSR&D IIR study (Kunik) and subsequently modified using data obtained from our SC MIRECC funded trial (Cully). CBT treatment will involve weekly sessions over a period of 6 weeks using a modular approach to care via in-person and telephone sessions. Four bi-weekly follow-up telephone booster sessions will be used to maintain and solidify changes. In total, CBT will involve 16 weeks of care. Patients assigned to UC will be provided with educational materials, routine assessments, and will be encouraged to seek additional care through their existing VA providers.

The proposed CDA-2 is designed to improve mental health care for chronically ill veterans by identifying and addressing patient-level barriers related to mental health treatment engagement (attainment of care). A CDA will provide faculty development time, as well as specific educational and experiential opportunities to develop a psychosocial intervention tailored to depressed and anxious veterans who are at increased risk for non-detection and under-treatment of their mental health conditions, namely chronically ill older adults with congestive heart failure receiving care outside mental health specialty clinics. The proposed CDA is specifically designed to develop a psychosocial intervention program.
As part of this 3-year award application, the PI and assembled mentoring team have created a series of training objectives and research projects to maximize the impact of this work on veteran care and to facilitate the PI's goal to become an independently funded health services researcher. Training objectives for this award include: 1) expanding the PI's psychological training to include greater knowledge of congestive heart failure and the impact of depression and anxiety in patients with CHF; and 2) obtaining advanced skills in the areas of qualitative / mixed method designs, psychosocial intervention development, and clinical trial methods.

The proposed training objectives will be accomplished through close mentoring, CHF shadowing experiences, seminars, and formal coursework. The proposed research plan includes a series of 3 studies which sequentially build upon each other, moving from exploratory analyses and survey construction, to intervention development and open clinical trial, and eventually to a small randomized controlled trial testing the effectiveness of the intervention against enhanced usual care. Ultimately, these training and research efforts will lead to larger grant initiatives designed to improve mental health engagement through implementation efforts embedded within existing VA mental health initiatives (e.g., hospital-based programs and research programs, such as TIDES/WAVES).

Not yet available.

The CDA had a dramatic impact on the investigator's development and contributions to the scientific and clinical care communities. Selected examples of the products produced by the award include:


Improving Depression and Anxiety Symptoms (in COPD) using Cognitive Behavioral Therapy. American Thoracic Society International Conference. New Orleans, LA May 14-19.
Cully JA, Stanley MA, Kunik ME (2008). Transforming psychotherapy for medically ill veterans with depression and anxiety. Presented at the Veterans Affairs Health Services Research and Development Career Development Award Conference, Baltimore, MD, February.

Khan MM, Zimmer MP, Petersen LA, Cully JA (2008). Quality of Depression Care, Health Service Use, and Mortality over a 6-Year Period. Presented at the 26th annual Veterans Affairs Health Services Research and Development Conference, Baltimore, MD, February.

Cully JA, Tolpin L, Henderson L, Kunik ME, Petersen LA (2008). Psychotherapy in the Veterans Health Administration: Missed Opportunities. Poster Presented at the 29th Society of Behavioral Medicine Annual Meeting, San Diego, CA, March.

Cully JA, Phillips LL, Stanley MA, Kunik ME (2008). Depression, Anxiety, and Quality of Life in Congestive Heart Failure. Paper Presented at the 29th Society of Behavioral Medicine Annual Meeting, San Diego, CA, March.

Paukert, A. L., LeMaire, A., & Cully, JA. (November, 2008). Predictors of depressive symptoms in veterans with congestive heart failure. Poster session presented at the annual meeting of the Gerontological Society of America, Washington, D.C.

Phillips, L. L., Falco, J.M., Paukert, A.L., Balsis, S., & Cully, J.A. (2008, November). Effects of a Brief Skills-Based Intervention on Quality of Life and Negative Affect among Older Chronically Ill Veterans. Poster accepted for the 61st Annual Gerontological Society of America Conference, Washington D.C.

Peer-reviewed manuscripts:

Cully JA, Stanley MA, Deswal A, Hanania N, Phillips LL, Kunik ME. Cognitive-Behavioral Therapy for Chronic Cardiopulmonary Conditions: Moving Beyond Mental Health Outcomes. Primary Care Companion J. Clin Psychiatry 2010 12 (4).

Cully JA, Jimenez D, Ledoux T, Deswal, A (2009). Recognition and treatment of depression and anxiety in congestive heart failure. J Clin Psychiatry Primary Care Companion, 11 (3), 103-109.

Paukert AL, LeMaire A, Cully JA* (2009). Predictors of Depressive Symptoms in Older Veterans with Congestive Heart Failure. Aging and Mental Health 13 (4), 601-610. * senior author

Cully JA, Paukert A, Falco J, Stanley MA (2009). Cognitive-Behavioral Therapy: Innovations for Cardiopulmonary Patients with Depression and Anxiety. Cognitive and Behavioral Practice, 16, 394-407.

Cully JA, Johnson M, Moffett ML, Khan M, Deswal A (2009). Depression and Anxiety in Ambulatory Patients with Heart Failure. Psychosomatics, 50, 592-598. PMID: 19996230

Cully JA, Phillips LL, Kunik ME, Stanley MA, Deswal A (2010). Predicting Quality of Life in Veterans with Heart Failure: The Role of Disease Severity, Depression, and Anxiety. Behavioral Medicine, 36: 70-76.

Cully JA, Teten AL, Benge J, Sorroco KH, Kauth MR (2010). Multidisciplinary Cognitive Behavioral Therapy Training for the VA Primary Care Setting. J Clin Psychiatry Primary Care Companion, 12 (3): e1-e8.

Cully JA, Tolpin L, Henderson L, Jimenez D, Kunik ME, Petersen LA (2008). Psychotherapy in the veterans health administration: Missed opportunities? Psychological Services, 5(4), 320-331.

Kunik ME, Azzam PN, Souchek J, Cully JA, Wray NP, Krishnan LL, Nelson HA, Stanley MA (2007). A practical screening tool for anxiety and depression in patients with chronic breathing disorders. Psychosomatics Jan-Feb; 48, 16-21. PMID: 17209145

Quijano LM, Stanley MA, Petersen NJ, Casado BL, Steinberg EH, Cully JA, & Wilson NL (2007). Healthy I.D.E.A.S: A depression intervention delivered by community-based case managers serving older adults. Journal of Applied Gerontology, 26 ,139-156.

Cully JA, Graham DP, Stanley MA, Kunik ME (2007). Depressed and Anxious COPD Patients: Predictors of Psychotherapy Engagement from a Clinical Trial. Journal of Clinical Psychology in Medical Settings, 14, 160-164.

Kunik, M.E., Veazey, C., Cully, J.A., Souchek, J., Graham, D.P., Hopko, D., Carter, R., Sharafkhanek, A., Goepfert, E.J., Wray, N., Stanley, M.A (2008). COPD education and cognitive behavioral therapy group treatment for clinically significant symptoms of depression and anxiety in COPD patients: a randomized controlled trial. Psychological Medicine, 38, 385-396. PMID: 17922939

Orengo CA, Khan J, Kunik ME, Snow AL, Morgan R, Steele A, Cully JA, Graham DP (2008). Aggression in individuals newly diagnosed with dementia. American Journal of Alzheimer's Disease and Other Dementias, 23, 227-232. PMID: 18258723

Cully JA, Zimmer M, Khan M, Petersen LA (2008). Quality of depression care: Impact on health service use and mortality among veterans. Psychiatric Services, 59, 1399-1405. PMID: 19033166

Current Grant Funding:

Cognitive Behavioral Therapy in Primary Care: Treating the Medically Ill
Veterans Administration Health Services Research and Development IIR
Principal Investigator
35% effort
Grant (IIR 09-088)

CBT for Late-Life GAD in Primary Care: Enhancing Outcomes and Translational
National Institute of Mental Health
Co-Investigator (Melinda Stanley, PhD Principal Investigator)
05/2008 - 04/2013
10% effort

Test of an intervention to improve retention in HIV care after hospitalization
National Institute of Mental Health, NIMH
Co- Investigator (Thomas Giordano, MD Principal Investigator)
09/30/09 - 07/31/14
10% effort
Grant: R01 MH085527-01A1

Developing an Intervention to Retain HIV-infected Veterans in HIV Care
Veterans Administration, Health Services Research and Development IIR
Co-Investigator (Giordano - PI)
10% effort
Total funding $850,500

Grants Pending
Behavioral Activation Therapy for Rural Veterans with Diabetes and Depression
Veterans Administration, Health Services Research and Development IIRc. Dual Principal Investigator (with A. Naik, MD)
Pending (second submission score 253)
25% effort
Total funding $1,043,000

External Links for this Project

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None at this time.

DRA: Mental, Cognitive and Behavioral Disorders
DRE: Treatment - Observational, Diagnosis
Keywords: Cardiovasc’r disease
MeSH Terms: none

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