Supported Online Self-Help for Veterans With Depression in Primary Care

Background: VA's Primary Care-Mental Health Integration (PCMHI) 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 PCMHI enabled specialists to support medication treatment in primary care, access to psychotherapy is not timely and sufficient. Alternative therapy modalities are needed. Peer-supported cCBT for depression has been shown to be effective but is not yet widely used within VA.

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 PCMHI models to enable better primary care patient access to effective psychotherapies, Veteran engagement in depression treatment is unlikely to improve.

Innovation: This study aims to close the gap in psychotherapy access for VA primary care patients with depression by adapting PCMHI collaborative care models to improve uptake of peer-supported computerized cognitive behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in more than 30 trials. With peer specialist support, it is comparable to face-to-face psychotherapy. Peer support specialists and PCMHI teams 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/Methodology: This study involves 400 recent military service members and Veterans in VA Greater Los Angeles and San Diego. VA providers help service members undergoing discharge at military treatment facilities transition to the VA for care. Once at the VA, providers screen patients every year for depression. This randomized clinical trial will study the implementation and effectiveness of online therapy for depression. First, to help providers deliver and monitor online treatment, we will use three tested strategies for implementation: facilitators/coaches, quality improvement, and data monitoring/dashboards. Second, we will randomly assign patients who are newly diagnosed with depression to receive either: 1) online therapy supported by Veterans peers and VA PCMHI clinical teams (SOS-D intervention), or 2) online therapy supported by VA PCMHI clinical teams alone (enhanced usual care). Our research team will measure and compare depressive symptoms at the study start then at 3 months and 6 months across both groups. We will measure how much online therapy is used by each group. Third, through interviews we will compare the experiences of women Veterans and patients with TBI using online therapy to men Veterans and those without TBI.

Next Steps/Implementation: This research will demonstrate how online depression treatment can be given to military service members, Veterans, and civilians on a larger scale. Bringing Veteran peers onto VA clinical teams can enhance use of online therapy for depression and support Veteran recovery. Ensuring depression treatment is available immediately when needs are identified is important in preventing suicide.

Inclusion criteria

• Must be enrolled in the VHA and currently receiving primary care services at VA Los Angeles or San Diego
• Have access to computer (mobile or desktop), internet, telephone, and email
• Able to read English text on a computer screen
• Score 10 or higher on the PHQ-9

Exclusion criteria

• Have moderate-high suicide risk (e.g. suicide flag) or active suicidality
• Have other serious mental illness (e.g. bipolar disorder, psychosis)
• Have medical disorder that would prevent/ interfere with participation (e.g. dementia/cognitive impairment, terminal illness)