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Implementing brief cognitive behavioral therapy in primary care: A pilot study

  • Original research
  • Published:
Translational Behavioral Medicine

ABSTRACT

Effective implementation strategies are needed to improve the adoption of evidence-based psychotherapy in primary care settings. This study provides pilot data on the test of an implementation strategy conducted as part of a multisite randomized controlled trial examining a brief cognitive-behavioral therapy versus usual care for medically ill patients in primary care, using a hybrid (type II) effectiveness/implementation design. The implementation strategy was multifaceted and included (1) modular-based online clinician training, (2) treatment fidelity auditing with expert feedback, and (3) internal and external facilitation to provide ongoing consultation and support of practice. Outcomes included descriptive and qualitative data on the feasibility and acceptability of the implementation strategy, as well as initial indicators of clinician adoption and treatment fidelity. Results suggest that a comprehensive implementation strategy to improve clinician adoption of a brief cognitive-behavioral therapy in primary care is feasible and effective for reaching high levels of adoption and fidelity.

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References

  1. Nash JM, McKay KM, Vogel ME, Masters KS. Functional roles and foundational characteristics of psychologists in integrated primary care. J Clin Psychol Med Settings. 2012; 19: 93-104.

    Article  PubMed  Google Scholar 

  2. Wray LO, Szymanski BR, Kearney LK, McCarthy JF. Implementation of primary care-mental health integration services in the Veterans Health Administration: program activity and association with engagement in specialty mental health services. J Clin Psychol Med Settings. 2012; 19: 105-116.

    Article  PubMed  Google Scholar 

  3. Veterans Health Administration. Uniform Mental Health Services in VA Medical Centers and Clinics (VHA Handbook 1160.01). Washington: Department of Veterans Affairs; 2008.

  4. Funderburk JS, Sugarman DE, Labbe AK, Rodrigues A, Maisto SA, Nelson B. Behavioral health interventions being implemented in a VA primary care system. J Clin Psychol Med Settings. 2011; 18: 22-29.

    Article  PubMed  Google Scholar 

  5. National Institute for Health and Clinical Excellence (NICE). Depression. The Treatment and Management of Depression in Adults (updated edition) [CG90]. London: National Institute for Health and Clinical Excellence; 2009.

  6. Stewart RE, Chambless DL. Cognitive behavioral therapy for adult anxiety disorders in clinical practice: a meta-analysis of effectiveness studies. J Consult Clin Psych. 2009; 77(4): 595-606.

    Article  Google Scholar 

  7. Cuijpers P, van Straten A, van Schaik A, Andersson G. Psychological treatment of depression in primary care: a meta-analysis. B J Gen Pract. 2009; 59: e51-e60.

    Article  Google Scholar 

  8. Cape J, Whittington C, Buszewicz M, Wallace P, Underwood L. Brief psychological therapies for anxiety and depression in primary care: Meta-analysis and meta-regression. BMC Medicine. 2010; 8: 38.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Nieuwsma JA, Trivedi RB, McDuffie J, Kronish I, Benjamin D, Williams JW Jr. Brief Psychotherapy for Depression in Primary Care: A Systematic Review of the Evidence (VA-ESP Project #09-010). Washington: Department of Veterans Affairs, Veterans Health Administration; 2011.

    Google Scholar 

  10. Cully JA, Stanley MA, Deswal A, Hanania NA, Phillips LL, Kunik ME. Cognitive-behavioral therapy for chronic cardiopulmonary conditions: Preliminary outcomes from an open trial. Prim Care Companion J Clin Psychiatry 2010;12(4). Available at http://www.hsrd.research.va.gov/publications/esp/brief-psychotherapy-2011-REPORT.pdf. Published January, 2011. Accessed November 1, 2012.

  11. McHugh RK, Barlow DH. The dissemination and implementation of evidence-based psychological treatments: a review of current efforts. Am Psychol. 2010; 65: 73-84.

    Article  PubMed  Google Scholar 

  12. Cook JM, Schnurr PP, Biyanova T, Coyne JC. Apples don’t fall far from the tree: influences on psychotherapists’ adoption and sustained use of new therapies. Psychiatr Serv. 2009; 60: 671-676.

    Article  PubMed Central  PubMed  Google Scholar 

  13. Kauth MR, Sullivan G, Blevins D, et al. Employing external facilitation to implement cognitive behavioral therapy in VA clinics: A pilot study. Implement Sci. 2010; 5: 75.

    Article  PubMed Central  PubMed  Google Scholar 

  14. Stetler CB, Legro MW, Rycroft-Malone J, et al. Role of “external facilitation” in implementation of research findings: a qualitative evaluation of facilitation experiences in the Veterans Health Administration. Implement Sci. 2006; 1: 23.

    Article  PubMed Central  PubMed  Google Scholar 

  15. Glasgow RE, Lichtenstein E, Marcus AC. Why don’t we see more translation of health promotion research to practice? Rethinking the efficacy-to-effectiveness transition. Am J Public Health. 2003; 93(8): 1261-1267.

    Article  PubMed Central  PubMed  Google Scholar 

  16. Greenhalgh T, Robert G, Macfarlane F, Bate P, Kyriakidou O. Diffusion of innovation in service organizations: systematic review and recommendations. Milbank Q. 2004; 82(4): 581-629.

    Article  PubMed Central  PubMed  Google Scholar 

  17. Grol R, Wensing M, Eccles M, eds. Improving Patient Care: The Implementation of Change in Clinical Practice. Oxford: Elsevier; 2005.

    Google Scholar 

  18. Stetler CB. Stetler Model. In: Rycroft-Malone J, Bucknall T, eds. Evidence-Based Practice Series. Models and Frameworks for Implementing Evidence-Based Practice: Linking Evidence to Action. Oxford: Wiley-Blackwell; 2010: 51-82.

    Google Scholar 

  19. Kauth MR, Sullivan G, Cully J, Blevins D. Facilitating practice changes in mental health clinics: a guide for implementation development in health care systems. Psychol Serv. 2011; 8(1): 6-47.

    Article  Google Scholar 

  20. Meichenbaum D, Turk DC. Facilitating Treatment Adherence: A Practitioner’s Guidebook. New York: Plenum; 1987.

    Book  Google Scholar 

  21. Miller WR, Rollnick S. Motivational Interviewing: Preparing People for Change. 3rd ed. New York: Guilford; 2012.

    Google Scholar 

  22. Harvey G, Loftus-Hills A, Rycroft-Malone, et al. Getting evidence into practice: the role and function of facilitation. J Adv Nurs. 2002; 37(6): 577-588.

    Article  PubMed  Google Scholar 

  23. Kirchner J, Edlund C, Henderson K, Daily L, Parker LE, Fortney JC. Using a multilevel approach to implement a Primary Care Mental Health (PCMH) program. Fam Syst Health. 2010; 28: 161-174.

    Article  PubMed  Google Scholar 

  24. Sullivan G, Blevins D, Kauth MR. Translating clinical training into practice in complex mental health systems: toward opening the “black box” of implementation. Implement Sci. 2008; 33: 1-7.

    Google Scholar 

  25. Cully JA, Armento MEA, Mott J, et al. Brief cognitive behavioral therapy in primary care: a hybrid type 2 patient randomized effectiveness-implementation design. Implement Sci. 2012; 7(1): 64.

    Article  PubMed Central  PubMed  Google Scholar 

  26. Fletcher CM, Elmes PC, Fairburn MB, Wood CH. The significance of respiratory symptoms and the diagnosis of chronic bronchitis in a working population. BMJ. 1959; 2(5147): 257-266.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  27. Association NYH. Diseases of the Heart and Blood Vessels: Nomenclature and Criteria for Diagnosis. 6th ed. Boston: Little, Brown and Co.; 1964.

    Google Scholar 

  28. Kroenke K, Spitzer RL, Williams JB. The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001; 16: 606-613.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  29. Beck A, Steer R. Beck Anxiety Inventory Manual. Harcourt Brace and Company: San Antonio; 1990.

    Google Scholar 

  30. Cully JA, Paukert A, Falco J, Stanley MA. Cognitive-behavioral therapy: innovations for cardiopulmonary patients with depression and anxiety. Cogn Behav Pract. 2009; 16: 394-407.

    Article  Google Scholar 

  31. Kitson A, Rycroft-Maline J, Harvey G, McCormack B, Seers K, Titchen A. Evaluating the successful implementation of evidence into practice using the PARIHS framework: theoretical and practical challenges. Implement Sci. 2008; 3(1): 1.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Stetler CB, Damschroder LJ, Helfrich CE, Hagedorn HJ. A guide for applying a revised version of the PARIHS framework for implementation. Implement Sci. 2011; 6: 99.

    Article  PubMed Central  PubMed  Google Scholar 

  33. Cully JA, Curry AD, Ryan SR, et al. Development of a computer-aided training program for brief cognitive-behavioral therapy in primary care. Acad Psychiatry. 2011; in press.

  34. Cully JA, Mignogna J, Stanley MA, Malik A, Zeno D, Willcockson I. Development and pilot testing of a standardized training program for a patient-mentoring intervention to increase adherence to outpatient HIV care. AIDS Patient Care and STDs. 2012; 26: 165-172.

    Article  PubMed Central  PubMed  Google Scholar 

  35. Kitson A, Harvey G, McCormack B. Enabling the implementation of evidence based practice: a conceptual framework. Qual Health Care. 1998; 7: 149-158.

    Article  CAS  PubMed Central  PubMed  Google Scholar 

  36. Bleza B, Toobert DJ, Gasgow RE. RE-AIM for Program Planning: Overview and Applications. Washington: Center for Healthy Aging; 2007.

    Google Scholar 

  37. Veterans Health Administration. Uniform Mental Health Services in VA Medical Centers and Clinics: Local Implementation of Evidence-based Psychotherapies for Mental and Behavioral Health Conditions (VHA Handbook 1160.05). Washington: Department of Veterans Affairs; 2008.

  38. Noël PH, Lanham HJ, Palmer RF, Leykum LK, Parchman ML. The importance of relational coordination and reciprocal learning for chronic illness care within primary care teams. Health Care Manage Rev. 2013; 38(1): 20-28.

    Article  PubMed Central  PubMed  Google Scholar 

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Acknowledgments

The authors would like to thank Ms. Sonora Hudson and Ms. Emma Welch for their thoughtful review and editing of this manuscript.

Funding

This material is based upon work supported by the Department of Veterans Affairs (HSR&D grant IIR 09-088). It was also partly supported by the Department of Veterans Affairs, Veterans Health Administration, Office of Research and Development, the Center for Innovations in Quality, Effectiveness and Safety (CIN 13-413), and the South Central Mental Illness, Research, Education, and Clinical Center. The views expressed in this article are those of the authors and do not necessarily reflect the position or policy of the Department of Veterans Affairs, the US government, or Baylor College of Medicine. None of these bodies played a role in study design; in the collection, analysis and interpretation of data; in the writing of the report; or in the decision to submit the article for publication.

Author information

Authors and Affiliations

  1. Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center (MEDVAMC 152), 2002 Holcombe Blvd., Houston, TX, 77030, USA

    Joseph Mignogna PhD, Natalie E Hundt PhD, Michael R Kauth PhD, Mark E Kunik MD, MPH, Aanand D Naik MD, Melinda A Stanley PhD & Jeffrey A Cully PhD

  2. Baylor College of Medicine, Houston, TX, USA

    Joseph Mignogna PhD, Natalie E Hundt PhD, Michael R Kauth PhD, Mark E Kunik MD, MPH, Aanand D Naik MD, Melinda A Stanley PhD & Jeffrey A Cully PhD

  3. VA South Central Mental Illness Research, Education and Clinical Center, Houston, TX, USA

    Joseph Mignogna PhD, Natalie E Hundt PhD, Michael R Kauth PhD, Mark E Kunik MD, MPH, Melinda A Stanley PhD & Jeffrey A Cully PhD

  4. Oklahoma Veterans Affairs Medical Center, Oklahoma City, OK, USA

    Kristen H Sorocco PhD

  5. University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA

    Kristen H Sorocco PhD

  6. Michael E. DeBakey VA Medical Center, Houston, TX, USA

    Kaki M York PhD

Authors
  1. Joseph Mignogna PhD
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  2. Natalie E Hundt PhD
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  3. Michael R Kauth PhD
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  4. Mark E Kunik MD, MPH
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  5. Kristen H Sorocco PhD
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  6. Aanand D Naik MD
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  7. Melinda A Stanley PhD
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  8. Kaki M York PhD
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  9. Jeffrey A Cully PhD
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Corresponding author

Correspondence to Joseph Mignogna PhD.

Additional information

Trial registration: NCT01149772 at http://www.clinicaltrials.gov/ct2/show/NCT01149772

Implications

Practice: Comprehensive implementation strategies hold the potential to improve clinician comfort and skill using standardized brief evidence-based psychotherapies delivered within the primary care setting.

Policy: Resources should be allocated to support multicomponent implementation strategies, including facilitative efforts to provide ongoing consultation and support of practice, to improve the adoption and fidelity of evidence-based psychotherapy practices in primary care settings.

Research: Research efforts should continue to test multicomponent implementation strategies to advance best practices for improving the utilization of evidence-based mental health treatments in primary care settings.

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Mignogna, J., Hundt, N.E., Kauth, M.R. et al. Implementing brief cognitive behavioral therapy in primary care: A pilot study. Behav. Med. Pract. Policy Res. 4, 175–183 (2014). https://doi.org/10.1007/s13142-013-0248-6

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  • DOI: https://doi.org/10.1007/s13142-013-0248-6

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