Analyzing free-text survey responses: An accessible strategy for developing patient-centered programs and program evaluation.

Despite widespread availability of yoga in the Veterans Health Administration (VA), it remains unclear how to best evaluate yoga programs. This is particularly problematic for programs aimed at veterans with mental health concerns, as evaluation typically focuses narrowly upon mental health symptom severity, even though program participants may have other health-related priorities. We analyzed responses to free-text questions on 237 surveys completed by veterans with mental health concerns enrolled in a yoga program at six VA clinics in Louisiana to characterize veteran participants' experiences with yoga. Qualitative analysis resulted in 15 domains reflecting veterans' individual health-related values and priorities. We use results to illustrate the potential for analysis of free-text responses to reveal valuable insights into patient experiences, demonstrating how these data can inform patient-centered program evaluation. The approach we present is more accessible to those responsible for decision-making about local programs than conventional methods of analyzing qualitive evaluation data.

Using implementation facilitation to implement primary care mental health integration via clinical video telehealth in rural clinics: protocol for a hybrid type 2 cluster randomized stepped-wedge design.

BACKGROUND: Integrating mental health providers into primary care clinics improves access to and outcomes of mental health care. In the Veterans Health Administration (VA) Primary Care Mental Health Integration (PCMHI) program, mental health providers are co-located in primary care clinics, but the implementation of this model is challenging outside large VA medical centers, especially for rural clinics without full mental health staffing. Long wait times for mental health care, little collaboration between mental health and primary care providers, and sub-optimal outcomes for rural veterans could result. Telehealth could be used to provide PCMHI to rural clinics; however, the clinical effectiveness of the tele-PCMHI model has not been tested. Based on evidence that implementation facilitation is an effective implementation strategy to increase uptake of PCMHI when delivered on-site at larger VA clinics, it is hypothesized that this strategy may also be effective with regard to ensuring adequate uptake of the tele-PCMHI model at rural VA clinics. METHODS: This study is a hybrid type 2 pragmatic effectiveness-implementation trial of tele-PCMHI in six sites over 24 months. Tele-PCMHI, which will be delivered by clinical staff available in routine care settings, will be compared to usual care. Fidelity to the care model will be monitored but not controlled. We will use the Reach Effectiveness Adoption Implementation Maintenance (RE-AIM) framework to evaluate the patient-level clinical effectiveness of tele-PCMHI in rural VA clinics and also to evaluate the fidelity to and outcomes of the implementation strategy, implementation facilitation. The proposed study will employ a stepped-wedge design in which study sites sequentially begin implementation in three steps at 6-month intervals. Each step will include (1) a 6-month period of implementation planning, followed by (2) a 6-month period of active implementation, and (3) a final period of stepped-down implementation facilitation. DISCUSSION: This study will evaluate the effectiveness of PCMHI in a novel setting and via a novel method (clinical video telehealth). We will test the feasibility of using implementation facilitation as an implementation strategy to deploy tele-PCMHI in rural VA clinics. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT02713217 . Registered on 18 March 2016.

Utilization of VA mental health and primary care services among Iraq and Afghanistan veterans with depression: the influence of gender and ethnicity status.

The objective of this study is to examine gender and ethnic differences in Veterans Affairs (VA) health services utilization among Iraq and Afghanistan military Veterans diagnosed with depression. With VA administrative data, sociodemographics, utilization of outpatient primary care, specialty mental health and mental health treatment modalities (psychotherapy and antidepressant prescriptions) were collected from electronic medical records of 1,556 depressed Veterans treated in one VA regional network from January 2008 to March 2009. Health care utilization patterns were examined 90 days following being diagnosed with depression. χ(2) and t-tests were used to evaluate unadjusted differences in VA service use by gender and ethnicity. Logistic regression was used to fit study models predicting VA service utilization. Study results indicate no ethnic or gender differences in the use of specialty mental health services or in the use of mental health treatments. However, women Veterans, especially those from ethnic minority groups, were less likely to use primary care than white and nonwhite male Veterans. Collectively, these findings signal a decrease in historically documented disparities within VA health care, especially in the use of mental health services.

Patient acceptance of and initiation and engagement in telepsychotherapy in primary care.

OBJECTIVE: The study examined factors associated with the utilization of psychotherapy offered in primary care via videoconferencing (telepsychotherapy). METHODS: Primary care patients with depression (N=179) recruited from five Federally Qualified Health Centers were randomly assigned to telemedicine-based collaborative care and offered free telepsychotherapy. Independent variables included measures of access to and need for treatment. Logistic regression identified variables associated with acceptability of and initiation and engagement in telepsychotherapy. RESULTS: To 76% of patients the idea of participating in psychotherapy was acceptable. Thirty-eight percent scheduled a telepsychotherapy session, 17% attended a session, and 8% engaged in treatment (attended at least eight sessions). Because the intervention was designed to minimize barriers, access was not a significant predictor of utilization. However, use of telepsychotherapy was associated with measures of perceived need. CONCLUSIONS: Even when psychotherapy was delivered in a primary care setting via videoconferencing to minimize barriers, few patients initiated or engaged in telepsychotherapy.

A description of telemental health services provided by the Veterans Health Administration in 2006-2010.

OBJECTIVE: This is the first large-scale study to describe the types of telemental health services provided by the Veterans Health Administration (VHA). METHODS: The authors compiled national-level VHA administrative data for fiscal years 2006-2010 (October 1, 2005, to September 30, 2010). Telemental health encounters were identified by VHA and U.S. Department of Veterans Affairs stop codes and categorized as medication management, individual psychotherapy with or without medication management, group psychotherapy, and diagnostic assessment. RESULTS: A total of 342,288 telemental health encounters were identified, and each type increased substantially across the five years. Telepsychotherapy with medication management was the fastest growing type of telemental health service. CONCLUSIONS: The use of videoconferencing technology has expanded beyond medication management alone to include telepsychotherapy services, including both individual and group psychotherapy, and diagnostic assessments. The increase in telemental health services is encouraging, given the large number of returning veterans living in rural areas.

Mental health needs and service utilization by Hispanic immigrants residing in mid-southern United States.

PURPOSE: This study assessed mental health needs and service utilization patterns in a convenience sample of Hispanic immigrants. DESIGN: A total of 84 adult Hispanic participants completed a structured diagnostic interview and a semistructured service utilization interview with trained bilingual research assistants. RESULTS: In the sample, 36% met diagnostic criteria for at least one mental disorder. Although 42% of the sample saw a physician in the prior year, mental health services were being rendered primarily by religious leaders. The most common barriers to service utilization were cost (59%), lack of health insurance (35%), and language (31%). Although more women than men met criteria for a disorder, service utilization rates were comparable. Participants with a mental disorder were significantly more likely to have sought medical, but not psychiatric, services in the prior year and faced significantly more cost barriers than participants without a mental disorder. CONCLUSIONS: Findings suggest that Hispanic immigrants, particularly those with a mental illness, need to access services but face numerous systemic barriers. The authors recommend specific ways to make services more affordable and linguistically accessible.

Cognitive appraisals of specialty mental health services and their relation to mental health service utilization in the rural population.

PURPOSE: Rural individuals utilize specialty mental health services (eg, psychiatrists, psychologists, counselors, and social workers) at lower rates than their urban counterparts. This study explores whether cognitive appraisals (ie, individual perceptions of need for services, outcome expectancies, and value of a positive therapeutic outcome) of help-seeking for depression symptoms are related to the utilization of specialty mental health services in a rural sample. METHODS: Demographic and environmental characteristics, cultural barriers, cognitive appraisals, and depression symptoms were assessed in one model predicting specialty mental health service utilization (MHSU) in a rural sample. Three hypotheses were proposed: (1) a higher number of environmental barriers (eg, lack of insurance or transportation) would predict lower specialty mental health service utilization; (2) an increase in cultural barriers (stigma, stoicism, and lack of anonymity) would predict lower specialty mental health utilization; and (3) higher cognitive appraisals of mental health services would predict specialty mental health care utilization beyond the predictive capacities of psychiatric symptoms, demographic variables, environmental barriers, and cultural barriers. FINDINGS: Current depression symptoms significantly predicted lifetime specialty mental health service utilization. Hypotheses 1 and 2 were not supported: more environmental barriers predicted higher levels of specialty MHSU while cultural barriers did not predict specialty mental health service utilization. Hypothesis 3 was supported: cognitive appraisals significantly predicted specialty mental health service utilization. CONCLUSIONS: It will be important to target perceptions and attitudes about mental health services to reduce disparities in specialty MHSU for the rural population.

Depression literacy: rates and relation to perceived need and mental health service utilization in a rural American sample.

INTRODUCTION: Mental health literacy assists patients to recognize, manage and prevent emotional disorders such as depression. Depression literacy is a specific type that varies among populations; however, there is a paucity of research on the depression literacy of rural Americans. The purposes of this study were to evaluate the depression literacy of a rural American sample, and to examine the relationship of depression literacy with perceived need for and utilization of different types of services for those with emotional problems. METHODS: Participants were recruited outside grocery stores in rural towns by consenting to be contacted and providing contact information. They were contacted via telephone to complete a survey of 15 min duration. Depression literacy was measured by assessing participants' ability to correctly label a vignette that depicted depressive symptoms. Demographic data, psychiatric symptoms, perceived need for seeking services (primary care, counselor and religious leader), and lifetime utilization of services (medical, specialty mental health and religious leader) for emotional problems were also assessed in the survey. RESULTS: High depression literacy (i.e., able to correctly label the vignette) was found in 53% of the sample. Men had lower depression literacy than women (35% vs 68%) and this effect remained after controlling for demographic and symptom variables. Multivariable regression analyses revealed that, after including demographic and symptoms variables in the regression equation, depression literacy did not significantly predict perceived need for a doctor, counselor, or religious leader, but depression literacy did significantly predicted utilization of a religious leader (but not a doctor or counselor). CONCLUSIONS: The rate of depression literacy in this sample was lower than the rates in other samples, especially among men. The disparity in depression literacy among men in this sample is consistent with the literature. Differences in utilization of a religious leader among those with high depression literacy may be due to differing cultural understandings of depression. Further research is needed to better understand this, and to examine larger and more urban samples. Future directions in rural depression literacy may focus on the knowledge, attitudes, and beliefs that rural men have about depression and how this affects help-seeking; and how to design interventions to improve depression literacy in this population.

A budget impact analysis of telemedicine-based collaborative care for depression.

BACKGROUND: Patients with depression use more health services than patients without depression. However, when depression symptoms respond to treatment, use of health services declines. Most depression quality improvement studies increase total cost in the short run, which if unevenly distributed across stakeholders, could compromise buy-in and sustainability. The objective of this budget impact analysis was to examine patterns of utilization and cost associated with telemedicine-based collaborative care, an intervention that targets patients treated in small rural primary care clinics. METHODS: Patients with depression were recruited from VA Community-based Outpatient Clinics, and 395 patients were enrolled and randomized to telemedicine-based collaborative care or usual care. Dependent variables representing utilization and cost were collected from administrative data. Independent variables representing clinical casemix were collected from self-report at baseline. RESULTS: There were no significant group differences in the total number or cost of primary care encounters. However, as intended, patients in the intervention group had significantly greater depression-related primary care encounters (marginal effect=0.34, P=0.004) and cost (marginal effect=$61.4, P=0.013) to adjust antidepressant therapy for nonresponders. There were no significant group differences in total mental health encounters or cost. However, as intended, the intervention group had significantly higher depression-related mental health costs (marginal effect=$107.55, P=0.03) due to referrals of treatment-resistant patients. Unexpectedly, patients in the intervention group had significantly greater specialty physical health encounters (marginal effect =0.42, P=0.001) and cost (marginal effect =$490.6, P=0.003), but not depression-related encounters or cost. Overall, intervention patients had a significantly greater total outpatient cost compared with usual care (marginal effect=$599.28, P=0.012). CONCLUSIONS: Results suggest that telemedicine-based collaborative care does not increase total workload for primary care or mental health providers. Thus, there is no disincentive for mental health providers to offer telemedicine-based collaborative care or for primary care providers to refer patients to telemedicine-based collaborative care.

Relationship between satisfaction, patient-centered care, adherence and outcomes among patients in a collaborative care trial for depression.

Collaborative care is known to improve satisfaction, patient-centered care, adherence, and depression symptom severity. However, associations among these outcomes have not been examined. Outcomes were measured at 6 months for 360 primary care patients with depression enrolled in a randomized trial of collaborative care. Main effects and mediation effects were examined using logistic regression analyses. Collaborative care significantly improved both satisfaction and patient-centered care. Patient-centered care did not mediate the positive effect that collaborative care had on satisfaction. Improvements in symptom severity partially mediated collaborative care's effect on satisfaction. Satisfaction did not mediate collaborative care's positive effect on antidepressant adherence.

Does minority racial-ethnic status moderate outcomes of collaborative care for depression?

OBJECTIVE: The authors examined racial differences in response rates to an intervention involving collaborative care and usual care among 360 veterans treated for depression at Department of Veterans Affairs community-based primary care clinics. METHODS: Individuals who screened positive for depression were assigned randomly to usual care (N=200) or to a collaborative care intervention (N=160) that provided phone contact when necessary with a registered nurse and clinical pharmacist to address issues related to compliance with medication and side effect management as well as supervision by a psychiatrist through video chats with the collaborative care team. Data about patients' characteristics, treatment history, and response to treatment were collected by telephone at baseline and after six months. RESULTS: Seventy-five percent (N=272) of the veterans were Caucasian, and 25% (N=88) belonged to a minority group, including 18% (N=64) who were African American, 3% (N=11) who were Native American, and 3.6% (N=13) who were of other minority groups. There were no significant differences between response rates between the Caucasian and minority group to usual care (18% and 8%, respectively), but the minority group had a higher response rate (42%) than Caucasians (19%) to the intervention (χ²=8.2, df=1, p=.004). Regression analysis indicated that the interaction of minority group status by intervention significantly predicted response (odds ratio [OR]=6.2, 95% confidence interval [CI]=1.6-24.5, p=.009), even after adjustment for other factors associated with minority status (OR=6.0, 95% CI=1.5-24.3, p=.01). CONCLUSIONS: Racial disparities in depression care may be ameliorated through collaborative care programs.