Leveraging COVID-19 to modernize depression care for VA primary care populations

Background: As part of comprehensive suicide prevention, VA integrated mental and physical health services to better detect and treat depression. Primary care nurses conduct screening annually. Clinicians, including Primary Care Mental Health Integration (PC-MHI) specialists, follow up as-needed for treatment. Depression detection and management processes are complex, involve multilevel stakeholders, and subject to significant disruption from COVID-19 and from resulting expansion of telehealth aiming to preserve care access. Fewer VA visits during the pandemic may signify lowered depression care quality and worsened patient outcomes. Significance: Depression affects 1 in 5 Veterans and is a leading cause of suicidality and disability. It contributes substantially to the current pandemic-related mental health crisis. Depression symptoms, including suicidal thoughts/behaviors, and related functional impairment have increased since COVID onset. Partnering with Primary Care, Mental Health, and Connected Care leaders, we propose to study pandemic-related service disruptions for depression, which may help to mitigate acute care use and mortality in the Veteran population. We apply established depression quality indicators from our prior research to a broad national scale at a critical time. We will also obtain feedback to improve current hybrid (virtual/in-person) care models from VA providers and Veterans who screened positive, including those who were not detected to have depression. Specific Aims: To improve virtual and in-person services for the VA primary care population during recovery, this proposal will examine how the pandemic disrupted depression care delivery mechanisms, including expanded telehealth, and patient outcomes. Our Specific Aims are: 1) To examine engagement in guideline- concordant care for depression (virtual or in-person) following screening, before and during the pandemic; 2) To compare psychiatric emergency/hospital visits and mortality from suicide between Veterans who screened positive and were detected versus not detected to have depression by clinicians; 3) To understand VA patients' and providers' current perspectives on addressing new depressive episodes using virtual and in-person modalities during the pandemic and eventual recovery. Methodology: Given hypothesized care disruption (lowered care quality) during COVID-19, Aim 1 proposes to extend our preliminary VISN methods nationally to assess the VA population's trajectory from a new positive depression (and suicide-risk) screen to appropriate treatment (i.e., medication, therapy) in FY19-22/23. We will also examine the changing mix of virtual and in-person depression care delivered. Aim 2 will use interrupted time series analyses to explore the extent to which acute care use may be mitigated by clinician detection of depression nationally. We will also compare mortality rates between patients detected and not detected to have depression. Sub-analyses will reveal where (e.g., clinics with low PC-MHI access) and for whom (e.g., minorities) detection does not systematically occur, and downstream negative sequelae, to guide future intervention. Finally, Aim 3 will interview (1) 40 Veterans who were detected and not detected to have depression per Aims 1 & 2 about care-seeking behavior change, digital divide, etc. and (2) 40 VA primary care and PC-MHI providers about staffing shortage, telehealth adoption, etc. across three VAs (GLA, Syracuse, and Durham). In addition to contextualizing disrupted care findings, qualitative data will help isolate best practices on patient-to-provider and provider-to-provider (e.g., handoffs) interactions in hybrid depression care models. Next Steps/Implementation: The COVID-19 pandemic provides the VA with an opportunity to improve upon a system-wide proactive response to depression and suicide, one that is conceptualized to care for the entire Veteran population. This proposed research will provide the basis for testable hypotheses (e.g., acceptable virtual depression treatments in primary care), and clinical recommendations (e.g., satisfactory virtual provider- to-provider handoffs for new patient referrals), to improve virtual and in-person VA depression services.