From 2006 – 2008, Cory Bolkan worked as a postdoctoral fellow in health services research for the Veterans Affairs Puget Sound Health Care System in Seattle. She had just received her Ph.D. in human development and family sciences, with a focus on gerontology, from Oregon State University. It was the ideal background for a complex study that continues to seek systemic changes to help veterans with depression.
“The goal is to improve mental health care in a primary care setting,” said Bolkan, now an assistant professor of human development at WSU Vancouver.
Bolkan joined the Well-being Among Veterans Enhancement Study (WAVES) and the Translating Initiatives in Depression into Effective Solution (TIDES) studies as a co-investigator. These studies were embarking on a major research project on how to improve health care access and services for veterans, especially those with depression, by translating research-based collaborative care for depression into an approach that could be implemented in actual Veterans Health Administration settings.
Initially, researchers screened 28,000 veterans who had upcoming primary care appointments for depression, yielding a sample of 761 individuals (mostly men), with a mean age of 60, at 10 VA primary care clinics across the country. All participants screened positive for depression, and many reported multiple chronic health conditions.
Half of the sample received “collaborative care,” a model in which a care manager serves as liaison between the primary care provider and mental health specialist. “Some sites were really active, some were not,” Bolkan said. “But this is what research is like in the real world – outside of a controlled laboratory.” The others received usual care and had no care manager.
The researchers followed the sample vets for 18 months with surveys, interviews and health records. They asked about their use of health care, treatment preferences, anxiety, PTSD, alcohol use, family involvement, employment and other factors. “We’re tapping into what vets are saying and how they can help inform mental health and primary providers on how best to provide care,” Bolkan said.
The research has resulted in nine papers (some still in preparation). The findings point to the effectiveness of collaborative care and the benefits of person-centered care (e.g., respecting veterans preferences regarding provider type or family involvement). But implementing the evidence-based findings is a challenge. Indeed, collaborative care is now mandated by the VA as part of treatment, but even so, many patients aren’t getting it.
Change has to happen on three levels: the patient, the provider and the health care system. “How do we get them all to coalesce?” Bolkan asked.
For example, some vets may feel stigmatized by mental health treatment and may prefer not to go to a specialist for it; but could primary care providers, along with the patient’s family support, address their mental health needs satisfactorily? Family members are a key health-related social support resource for many patients and are the support system most commonly accessed by health care providers, but there is little information about how to guide this type of clinical care. “Many providers reported that a top priority was family involvement,” Bolkan said.
The research team recently conducted an expert panel that consisted of key VA clinicians and leaders across the United States, for discussion about redesigning collaborative care and implementation programs based on the outcomes of the TIDES and WAVES projects. They are now compiling comments for delivery to the VA later this year or in early 2016.