Patient-centered primary care for adults at high risk for AUDs: the Choosing Healthier Drinking Options In primary CarE (CHOICE) trial.

BACKGROUND: Most patients with alcohol use disorders (AUDs) never receive alcohol treatment, and experts have recommended management of AUDs in primary care. The Choosing Healthier Drinking Options In primary CarE (CHOICE) trial was a randomized controlled effectiveness trial of a novel intervention for primary care patients at high risk for AUDs. This report describes the conceptual and scientific foundation of the CHOICE model of care, critical elements of the CHOICE trial design consistent with the Template for Intervention Description and Replication (TIDieR), results of recruitment, and baseline characteristics of the enrolled sample. METHODS: The CHOICE intervention is a multi-contact, extended counseling intervention, based on the Chronic Care Model, shared decision-making, motivational interviewing, and evidence-based options for managing AUDs, designed to be practical in primary care. Outpatients who received care at 3 Veterans Affairs primary care sites in the Pacific Northwest and reported frequent heavy drinking (≥4 drinks/day for women; ≥5 for men) were recruited (2011-2014) into a trial in which half of the participants would be offered additional alcohol-related care from a nurse. CHOICE nurses offered 12 months of patient-centered care, including proactive outreach and engagement, repeated brief motivational interventions, monitoring with and without alcohol biomarkers, medications for AUDs, and/or specialty alcohol treatment as appropriate and per patient preference. A CHOICE nurse practitioner was available to prescribe medications for AUDs. RESULTS: A total of 304 patients consented to participate in the CHOICE trial. Among consenting participants, 90% were men, the mean age was 51 (range 22-75), and most met DSM-IV criteria for alcohol abuse (14%) or dependence (59%). Many participants also screened positive for tobacco use (44%), depression (45%), anxiety disorders (30-41%) and non-tobacco drug use disorders (19%). At baseline, participants had a median AUDIT score of 18 [Interquartile range (IQR) 14-24] and a median readiness to change drinking score of 5 (IQR 2.75-6.25) on a 1-10 Likert scale. CONCLUSION: The CHOICE trial tested a patient-centered intervention for AUDs and recruited primary care patients at high risk for AUDs, with a spectrum of severity, co-morbidity, and readiness to change drinking. Trial registration The trial is registered at clinicaltrial.gov (NCT01400581).

Feasibility and acceptability of a telephone psychotherapy program for depressed adults treated in primary care.

OBJECTIVE: Telephone psychotherapy is an emerging model of care that appears feasible for extending the reach of evidence-based psychotherapy treatment without accruing the full costs of traditional office-based, mental health care. This manuscript describes the development, implementation and acceptance of a 12-month telephone psychotherapy program (TPP) for depressed adults not fully responding to standard antidepressant treatment in primary care. METHOD: The TPP combined a population-based medication monitoring and information system with a structured cognitive-behavioral treatment (CBT) program. The TPP included 8-12 telephone sessions (eight core CBT sessions and three to four clinical booster sessions) delivered by a master-level therapist working in tandem with each patient's primary care physician (PCP). RESULTS: The TPP was well accepted (i.e., 80% completed the core program) by a population-based sample of adult primary care patients initiating antidepressant treatment. The mean duration of core telephone psychotherapy sessions was approximately 31 min during acute-phase treatment (0-6 months). Eighty-two percent of TPP patients maintained contact with their therapist during maintenance-phase treatment (6-12 months). CONCLUSIONS: The practical and efficient nature of this TPP appears to sidestep many of the treatment barriers encountered in traditional office-based care. Implementation of this TPP program in other primary care settings may be valuable for enhancing standard pharmacotherapy treatment of adult depression, especially among populations facing greater barriers of care.