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CDA 19-108 – HSR&D Study

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CDA 19-108
Improving Depression Management in Primary Care
Lucinda B Leung MD MPH PhD
West Los Angeles, CA
Funding Period: July 2020 - June 2025

Abstract

Background: VA’s Primary Care–Mental Health Integration (PC-MHI) is rooted in evidence-based collaborative care models, where care managers, mental health specialists, and primary care providers jointly treat depression in primary care. While PC-MHI enabled specialists to support medication treatment in primary care, timely and sufficient access to psychotherapy is unattainable. Alternative therapy modalities are needed. Significance/Impact: Depression is disabling and affects one in five Veterans. Psychotherapy is preferred by Veterans, but fraught with multilevel barriers (e.g., staff availability, patient travel to clinic, limited clinic hours). Without enhancing existing PC-MHI models to enable better primary care patient access to effective psychotherapies, Veteran engagement in depression treatment is unlikely to improve. Innovation: This CDA aims to close the gap in psychotherapy access for VA primary care patients with depression by adapting PC-MHI collaborative care models to improve uptake of computerized cognitive behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in more than 30 trials. With modest specialist support, it is non-inferior to face-to-face psychotherapy. PC-MHI can facilitate Veteran uptake of cCBT, using an evidence-based collaborative care model to provide the follow- up care management and mental health specialist back-up that characterizes the most effective cCBT trials. Specific Aims: This CDA will enable me to be a VA implementation scientist who designs, tests, implements, and disseminates effective collaborative care model improvements to treat depression in primary care. My Specific Aims are: (1) to adapt PC-MHI collaborative care to improve uptake of cCBT among VA primary care patients with depression, based on input from multilevel stakeholders; (2) to pilot test the feasibility, acceptability, and potential effects of cCBT-enhanced collaborative care on Veterans’ depression symptoms and related outcomes in one primary care clinic, in preparation for a larger, multi-site hybrid effectiveness- implementation trial; and (3) to establish expert consensus on the translation of pilot findings into a design for cCBT-enhanced collaborative care that is feasible locally, regionally and nationally in VA. Methodology: In Aim 1, I will use qualitative methods and elicit feedback from Veterans, VA providers, and other key stakeholders of national experts and operations leaders (CDA advisory group) to adapt the PC-MHI collaborative care model to improve cCBT uptake. In Aim 2, I will conduct a pilot randomized controlled trial (RCT) to examine feasibility, acceptability, and potential effects on depression, patient activation, and health- related quality of life in VA primary care patients with depression receiving either (1) cCBT-enhanced collaborative care (n=32) or (2) usual care (n=32) in West Los Angeles VA, from baseline to 2-months (post- intervention). This pilot will position me to conduct a multi-site hybrid type I effectiveness-implementation RCT. In Aim 3, I will conduct a virtual expert panel using modified Delphi methods to examine critical barriers and facilitators in the cCBT-enhanced collaborative care model for closing the gap in psychotherapy access for Veterans with depression and other illnesses in routine VA primary care, which will be informed by existing literature and VA-based pilot data. The CDA training and mentorship will facilitate my transition into an independent VA HSR&D investigator by filling explicit training gaps in implementation science (and qualitative methods), clinical trial design (for depression care), and health informatics. Next Steps/Implementation: Adapting PC-MHI’s collaborative care model to incorporate cCBT can improve access to psychotherapy and engage the ~400,000 untreated Veterans with depression who prefer psychotherapy, especially OIF/OEF/OND Veterans seeking care that is convenient. The CDA will provide mentorship and training to begin my career as an implementation scientist who leads collaborative care model improvements using novel technology to address unmet needs and preferences of Veterans in primary care.

NIH Reporter Project Information: https://reporter.nih.gov/project-details/9947795


PUBLICATIONS:

Journal Articles

  1. Puac-Polanco V, Ziobrowski H, Ross E, Liu H, Turner B, Cui R, Leung LB, Bossarte RM, Bryant C, Joormann J, Nierenberg AA, Oslin DW, Pigeon WR, Post EP, Zainal NH, Zaslavsky AM, Zubizarreta JR, Luedtke A, Kennedy CJ, Cipriani A, Furukawa TA, Kessler RC. Development of a model to predict antidepressant treatment response for depression among Veterans. Psychological medicine. 2022 Jul 15; 1-11.
  2. Der-Martirosian C, Chu K, Steers WN, Wyte-Lake T, Balut MD, Dobalian A, Heyworth L, Paige NM, Leung L. Examining telehealth use among primary care patients, providers, and clinics during the COVID-19 pandemic. BMC primary care. 2022 Jun 18; 23(1):155.
  3. Leung LB, Rubenstein LV, Jaske E, Wheat CL, Nelson KM, Felker BL. Contrasting Care Delivery Modalities Used by Primary Care and Mental Health Specialties in VA's Telehealth Contingency Staffing Program During the COVID-19 Pandemic. Journal of general internal medicine. 2022 Aug 1; 37(10):2607-2610.
  4. Leung LB, Chu K, Rose D, Stockdale S, Post EP, Wells KB, Rubenstein LV. Electronic Population-Based Depression Detection and Management Through Universal Screening in the Veterans Health Administration. JAMA Network Open. 2022 Mar 1; 5(3):e221875.
  5. Ziobrowski HN, Cui R, Ross EL, Liu H, Puac-Polanco V, Turner B, Leung LB, Bossarte RM, Bryant C, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Nierenberg AA, Luedtke A, Kennedy CJ, Kessler RC. Development of a model to predict psychotherapy response for depression among Veterans. Psychological medicine. 2022 Feb 11; 1-10.
  6. Leung LB, Rubenstein LV, Jaske E, Taylor L, Post EP, Nelson KM, Rosland AM. Association of Integrated Mental Health Services with Physical Health Quality Among VA Primary Care Patients. Journal of general internal medicine. 2022 Oct 1; 37(13):3331-3337.
  7. Leung LB, Benitez CT, Dorsey C, Mahajan AP, Hellemann GS, Whelan F, Park NJ, Braslow JT. Integrating Mental Health in Safety-net Primary Care: A Five-year Observational Study on Visits in a County Health System. Medical care. 2021 Nov 1; 59(11):975-979.
  8. Leung LB, Ziobrowski HN, Puac-Polanco V, Bossarte RM, Bryant C, Keusch J, Liu H, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Kessler RC. Are Veterans Getting Their Preferred Depression Treatment? A National Observational Study in the Veterans Health Administration. Journal of general internal medicine. 2022 Oct 1; 37(13):3235-3241.
  9. Leung LB, Rose D, Guo R, Brayton CE, Rubenstein LV, Stockdale S. Mental health care integration and primary care patient experience in the Veterans Health Administration. Healthcare (Amsterdam, Netherlands). 2021 Dec 1; 9(4):100587.
  10. Germack HD, Leung L, Zhao X, Zhang H, Martsolf GR. Association of Team-Based Care and Continuity of Care with Hospitalizations for Veterans with Comorbid Mental and Physical Health Conditions. Journal of general internal medicine. 2022 Jan 1; 37(1):40-48.
  11. Ziobrowski HN, Leung LB, Bossarte RM, Bryant C, Keusch JN, Liu H, Puac-Polanco V, Pigeon WR, Oslin DW, Post EP, Zaslavsky AM, Zubizarreta JR, Kessler RC. Comorbid mental disorders, depression symptom severity, and role impairment among Veterans initiating depression treatment through the Veterans Health Administration. Journal of affective disorders. 2021 Jul 1; 290:227-236.
  12. Puac-Polanco V, Leung LB, Bossarte RM, Bryant C, Keusch JN, Liu H, Ziobrowski HN, Pigeon WR, Oslin DW, Post EP, Kessler RC. Treatment Differences in Primary and Specialty Settings in Veterans with Major Depression. Journal of the American Board of Family Medicine : JABFM. 2021 Mar 1; 34(2):268-290.
  13. Leung LB, Steers WN, Hoggatt KJ, Washington DL. Explaining racial-ethnic differences in hypertension and diabetes control among veterans before and after patient-centered medical home implementation. PLoS ONE. 2020 Oct 12; 15(10):e0240306.
  14. Leung LB, Rubenstein LV, Post EP, Trivedi RB, Hamilton AB, Yoon J, Jaske E, Yano EM. Association of Veterans Affairs Primary Care Mental Health Integration With Care Access Among Men and Women Veterans. JAMA Network Open. 2020 Oct 1; 3(10):e2020955.
  15. Leung LB, Rose D, Rubenstein LV, Guo R, Dresselhaus TR, Stockdale S. Does Mental Health Care Integration Affect Primary Care Clinician Burnout? Results from a Longitudinal Veterans Affairs Survey. Journal of general internal medicine. 2020 Dec 1; 35(12):3620-3626.
  16. Leung LB, Dyer KE, Yano EM, Young AS, Rubenstein LV, Hamilton AB. Collaborative care clinician perceptions of computerized cognitive behavioral therapy for depression in primary care. Translational behavioral medicine. 2020 Aug 7; 10(3):565-572.
Journal Other

  1. Essien UR, Tipirneni R, Leung LB, Sterling MR. Surviving and Thriving as Leaders in General Internal Medicine-Reply. Journal of general internal medicine. 2021 May 1; 36(5):1435-1436.
  2. Leung LB, Young AS, Heyworth L, Rose D, Stockdale S, Graaff AL, Dresselhaus TR, Rubenstein LV. Do Collaborative Care Managers and Technology Enhance Primary Care Satisfaction with Care from Embedded Mental Health Providers? [Editorial]. Journal of general internal medicine. 2020 Dec 1; 35(12):3458-3464.
  3. Essien UR, Tipirneni R, Leung LB, Sterling MR. Surviving and Thriving as Physicians in General Internal Medicine Fellowship in the Twenty-First Century. Journal of general internal medicine. 2020 Dec 1; 35(12):3664-3670.


DRA: Mental, Cognitive and Behavioral Disorders, Health Systems
DRE: Treatment - Efficacy/Effectiveness Clinical Trial, Treatment - Implementation
Keywords: Career Development, Depression
MeSH Terms: None at this time.

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