BACKGROUND/RATIONALE:
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(S):
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 computer CALM program and those who use a manual version of CALM. We hypothesize that clinicians who use the CALM computer program, relative to the manual, will have higher fidelity to CBT and better clinical outcomes among Veteran patients. (3) Prepare for future implementation of the tool in the VA by conducting qualitative interviews with key stakeholders. Develop a 'tool-kit' for future implementation of the tool.

METHODS:
Aim 1 - to achieve Aim 1, we will conduct focus groups with key stakeholders.

Aim 2 - to achieve Aim 2, 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 CALM program. Thirty-four CBOC MH providers will be trained in CBT and randomized to use the CALM program or CALM manual. Both groups will receive external facilitation to encourage the full implementation of CBT into clinical practice. MH providers will treat 10 patients each. Patients will be assessed at baseline, 3-, and 6-month follow-up. Along with clinical outcomes, provider fidelity to the CBT protocol will be measured by evaluating audiotaped therapy sessions.

Aim 3 - to achieve Aim 3, we will conduct semi-structured telephone interviews with CBOC MH providers and CBOC directors. A tool kit for future implementation of the tool will be disseminated.

FINDINGS/RESULTS:
Specific Aim 1 Findings -
VA Calm web-tool is fully functioning and housed on the VA Server


Specific Aim 2 Findings -
a. Preliminary findings show that at three months post baseline, Veterans enrolled in the study demonstrate improvements in depression, PTSD, and anxiety symptom scores.





IMPACT:
We have had the following impacts:

A. We have trained 34 mental health providers, working in largely rural CBOCs in VISNs 16 and 17, in CBT (CALM version) for treating anxiety disorders, depression, and PTSD.

B. We have trained these providers to deliver CBT using either a computer program or manual version of the CALM protocol

C. We are collaborating with the EMPOWER QUERI group at the Greater Los Angeles VA, California as they are preparing to utilize the CALM web tool in their project to improve women Veterans mental health.

D. Our preliminary data suggest that CALM leads to improvements in clinical outcomes among Veterans enrolled in the study.

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External Links for this Project

NIH Reporter

Grant Number: I01HX001133-01
Link: https://reporter.nih.gov/project-details/8487141

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PUBLICATIONS:

Journal Articles

1. Abraham TH, Marchant-Miros K, McCarther MB, Craske MG, Curran GM, Kearney LK, Greene C, Lindsay JA, Cucciare MA. Adapting Coordinated Anxiety Learning and Management for Veterans Affairs Community-Based Outpatient Clinics: Iterative Approach. JMIR mental health. 2018 Aug 22; 5(3):e10277. [view]
2. Cucciare MA, Marchant K, Lindsay J, Craske MG, Ecker A, Day S, Hogan J, Henn J, LeBeau RT, Rabalais A, Rose RD, Qualls M, Treanor M, Abraham TH. An Evidence-Based Model for Disseminating-Implementing Coordinated Anxiety Learning and Management in Department of Veterans Affairs' Community-Based Outpatient Clinics. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2020 Jun 1; 36(3):371-380. [view]
3. Cucciare MA, Curran GM, Craske MG, Abraham T, McCarthur MB, Marchant-Miros K, Lindsay JA, Kauth MR, Landes SJ, Sullivan G. Assessing fidelity of cognitive behavioral therapy in rural VA clinics: design of a randomized implementation effectiveness (hybrid type III) trial. Implementation science : IS. 2016 May 10; 11(1):65. [view]
4. Ecker AH, Abraham TH, Martin LA, Marchant-Miros K, Cucciare MA. Factors Affecting Adoption of Coordinated Anxiety Learning and Management (CALM) in Veterans' Affairs Community-Based Outpatient Clinics. The Journal of rural health : official journal of the American Rural Health Association and the National Rural Health Care Association. 2021 Mar 1; 37(2):447-455. [view]

Conference Presentations

1. Zamora KA, Koenig CJ, Abraham TH, Pyne JM. The Diversity of Veteran Engagement in Mental Health Care. Paper presented at: Society for Applied Anthropology Annual Meeting; 2016 Mar 31; Vancouver, Canada. [view]

DRA: Mental, Cognitive and Behavioral Disorders, Health Systems Science
DRE: Treatment - Efficacy/Effectiveness Clinical Trial
Keywords: Anxiety Disorders, Cognitive Therapy, Depression, Effectiveness, Implementation, Outcomes - Patient, PTSD, Rural
MeSH Terms: none