Center for Care Delivery and Outcomes Research
Understanding the Integration of Evidence-Based Psychotherapies for Depression (INTEGRATE)
Depression is a highly prevalent mental health disorder that carries a heavy disease burden and is the 2nd
leading risk factor for suicide among Veterans. VA has disseminated three effective psychotherapies for
depression to VA clinics, but therapist use of these treatments is <12%. Surprisingly, no studies have
examined the provision of evidence-based psychotherapies for depression (D-EBPs) in VA and reasons
underlying infrequent delivery, leaving a critical gap in depression care delivery in VA. System factors are a
known driver of EBP use, and early signs from the Office of Mental Health’s efforts and unique factors related
to how depression care is organized in VA warrant an empirical investigation.
Low utilization of D-EBPs and the lack of empirical evidence on barriers is a significant problem for several
reasons. First, suicide prevention is a top priority in VA and across the nation and untreated depression is a
major risk factor for suicide. Second, effectiveness of existing interventions that target therapist-level barriers
cannot be maximized without data about system barriers. Increasing the reach of other EBPs (e.g., PTSD) has
required intervention at all levels (patient, therapist, and system) and the same is undoubtably true for D-EBPs.
Identifying and targeting system factors and exploring therapist factors and conducting the first exploration of
patient perceptions of D-EBPs will bolster these early therapist-focused interventions. Furthermore, this
proposal is timely in that it comes on the heels of the Office of Mental Health’s shift from assessing anticipated
barriers to D-EBP delivery during trainings to developing partnerships to understand barriers experienced in
the field. Finally, since this proposal is examining D-EBP delivery in specialty mental health clinics where other
mental health conditions are treated, findings have implications of EBPs for those other conditions. This 3.5-
year study is the first study to examine reasons for low utilization of depression EBPs by therapists in VA.
INTEGRATE aims to:
1) Quantitatively examine the association between health system factors and D-EBP delivery;
2) Qualitatively examine how contextual and system factors impact therapist decisions around the provision of
D-EBPs;
3) Develop a framework of intervention targets and potential solutions to reduce barriers to D-EBP use; and
4) Secondary/Exploratory Aims: a) Qualitatively explore how therapist factors impact D-EBP use; b) Explore
patients’ perceptions of D-EBPs.
Using an explanatory sequential mixed-method design, in Aim 1 (quantitative) we extracted system-level and
EBP training data for FY22 from VA administrative databases. Findings showed that only 2.8% patients with
depression had a D-EBP session identified in their medical record. Gender, age, presence of mental health
comorbidities, depression medication use, clinic patient volume, and VA district were associated with D-EBP
use. Read more details here.
Analysis is underway for Aim 2 and secondary aims (qualitative) which included interviews with therapists
trained in at least one of the three D-EBPs and mental health leaders from 10 VA medical centers, and patients
from these sites to understand their perceptions of D-EBPs. Aim 3 will involve intervention mapping and Delphi
strategies to develop a framework for reducing system barriers to D-EBP delivery.