Expanding access to evidence-based psychotherapy in VA settings: implementation of the brief cognitive behavioral therapy for depression program.

Introduction: Evidence-based psychotherapies (EBPs) are effective for mental health conditions, but access to these services remains limited and rural Veterans are particularly underserved. Specialized implementation and dissemination programs are needed to improve access to known EBPs. Methods: The current project sought to improve access to a known EBP-brief Cognitive Behavioral Therapy for depression (Brief CBT). Diverse Veterans and those from rural settings were a focus of this work. Aligned with the RE-AIM framework, a multifaceted implementation program was used to train and support VHA providers in their use of Brief CBT in VHA mental health settings, with specific outreach efforts made to providers at VHA Community-Based Outpatient Clinics (CBOCs) where rural Veterans often receive care. Evaluation included all facets of RE-AIM with a particular focus on adoption, effectiveness, and maintenance. Results: During the first two years, over 40 VHA facilities adopted the program across four regional networks. Eighty-three providers were approached, and 54 (65.1%) providers completed the training and are delivering the intervention. A total of 688 Veterans, 174 rural (25.7%), received 2,186 sessions (average of 3.5 sessions per Veteran). Veterans receiving Brief CBT with elevated depression scores who completed three or more sessions were found to have significant symptom reductions of 4.6 points (first to last available evaluations). Discussion: Implementation efforts of Brief CBT resulted in rapid uptake and significant clinical impact on Veterans. Rural outreach efforts, including targeted training for CBOC providers and use of tele-mental health, enhanced availability of EBP services for rural Veterans.

Acceptance and Commitment Training for Veterans with Polytrauma: A randomized controlled trial protocol.

BACKGROUND: Mild traumatic brain injury (mTBI) is a signature wound of Veterans of operations in Iraq and Afghanistan (i.e., OIF/OEF/OND). Most Veterans with mTBI also experience stress-based psychopathology (e.g., depression, posttraumatic stress disorder) and chronic pain. This combination - referred to as polytrauma - results in detrimental long-term effects on social, occupational, and community reintegration. This study will compare the efficacy of a one-day Acceptance and Commitment Training plus Education, Resources, and Support (ACT+ERS) workshop to a one-day active control group (ERS) on symptoms of distress and social, occupational, and community reintegration. We will also examine mediators and moderators of treatment response. METHODS: This is an ongoing randomized clinical trial. 212 OIF/OEF/OND Veterans with polytrauma are being recruited. Veterans are randomly assigned to a one-day ACT+ERS or a one-day ERS workshop with two individualized booster sessions approximately two- and four-weeks post-workshop. Veterans complete assessments prior to the workshop and again at six weeks, three months, and six months post-workshop. Of note, workshops were converted to a virtual format due to the COVID-19 pandemic. RESULTS: The primary outcomes are symptoms of distress and reintegration; secondary outcomes are post-traumatic stress disorder symptoms and pain interference. Secondary analyses will assess whether changes in avoidance at three months mediate changes in distress and reintegration at six months. CONCLUSION: Facilitating the psychological adjustment and reintegration of Veterans with polytrauma is critical. The results of this study will provide important information about the impact of a brief intervention for Veterans with these concerns.

Combination outreach and wellness intervention for distressed rural veterans: results of a multimethod pilot study.

We partnered with veteran-serving nonprofits in order to identify distressed rural veterans and provide them with a mental health workshop in community-based settings. Community organizations helped recruit veterans and provided space for 1-day (5-h) Acceptance and Commitment Therapy (ACT) group workshops conducted in rural locations. Qualitative interviews were conducted at 1- and 3-months post-intervention to assess acceptability. Quantitative measures were conducted at baseline, 1- and 3-months post-intervention to measure effectiveness. We successfully engaged community partners throughout every stage of the research and delivered workshops to thirty-one veterans in rural community-based locations. Veterans appreciated the structure, content, and environment of the workshops; most implemented ACT skills into their daily lives and some initiated new treatment following workshop participation. Quantitative measures showed improvements in functioning (Cohen's d ranging from .27 to .40), reintegration (Cohen's d = .45), meaning and purpose (Cohen's d = .40), and reductions in distress (Cohen's d ranging from .28 to .40) 3-months following workshop participation. Collaborating with rural veteran-serving nonprofit organizations holds promise for engaging hard-to-reach distressed veterans in mental health care.