社区心理健康诊所中基于测量的抑郁症治疗的标准化与定制化实施。
Standardized Versus Tailored Implementation of Measurement-Based Care for Depression in Community Mental Health Clinics.
机构信息
Kaiser Permanente Washington Health Research Institute, Seattle (Lewis); Abacist Analytics, Austin, Texas (Marti); Department of Behavioral and Social Sciences, Brown University, Providence, Rhode Island (Scott); School of Public Health, University of North Carolina, Chapel Hill (Walker); Department of Psychology, University of California, Los Angeles, Los Angeles (Boyd); Mayo Clinic, Rochester, Minnesota (Puspitasari); RAND Corporation, Santa Monica, California (Mendel); Department of Medicine, Indiana University, Bloomington (Kroenke).
出版信息
Psychiatr Serv. 2022 Oct 1;73(10):1094-1101. doi: 10.1176/appi.ps.202100284. Epub 2022 May 11.
OBJECTIVE
Measurement-based care (MBC) is an evidence-based practice that is rarely integrated into psychotherapy. The authors sought to determine whether tailored MBC implementation can improve clinician fidelity and depression outcomes compared with standardized implementation.
METHODS
This cluster-randomized trial enrolled 12 community behavioral health clinics to receive 5 months of implementation support. Clinics randomized to the standardized implementation received electronic health record data captured with the nine-item Patient Health Questionnaire (PHQ-9), a needs assessment, clinical training, guidelines, and group consultation in MBC fidelity. Tailored implementation support included these strategies, but the training content was tailored to clinics’ barriers to MBC, and group consultation centered on overcoming these barriers. Clinicians (N=83, tailored; N=71, standardized) delivering individual psychotherapy to 4,025 adults participated. Adult patients (N=87, tailored; N=141, standardized) contributed data for depression outcome analyses.
RESULTS
The odds of PHQ-9 completion were lower in the tailored group at baseline (odds ratio [OR]=0.28, 95% CI=0.08–0.96) but greater at 5 months (OR=3.39, 95% CI=1.00–11.48). The two implementation groups did not differ in full MBC fidelity. PHQ-9 scores decreased significantly from baseline (mean±SD=17.6±4.4) to 12 weeks (mean=12.6±5.9) (p<0.001), but neither implementation group nor MBC fidelity significantly predicted PHQ-9 scores at week 12.
CONCLUSIONS
Tailored MBC implementation outperformed standardized implementation with respect to PHQ-9 completion, but discussion of PHQ-9 scores in clinician-patient sessions remained suboptimal. MBC fidelity did not predict week-12 depression severity. MBC can critically inform collaborative adjustments to session or treatment plans, but more strategic system-level implementation support or longer implementation periods may be needed.
目的
基于测量的护理（MBC）是一种基于证据的实践，很少被整合到心理治疗中。作者试图确定与标准化实施相比，量身定制的 MBC 实施是否可以提高临床医生的保真度和抑郁结果。
方法
这项集群随机试验招募了 12 家社区行为健康诊所，以接受 5 个月的实施支持。随机接受标准化实施的诊所收到了使用九项患者健康问卷（PHQ-9）、需求评估、临床培训、指南和 MBC 保真度小组咨询捕获的电子健康记录数据。定制实施支持包括这些策略，但培训内容针对诊所实施 MBC 的障碍进行了定制，小组咨询以克服这些障碍为中心。为 4025 名成年人提供个别心理治疗的临床医生（量身定制组 N=83，标准化组 N=71）参与了研究。成年患者（量身定制组 N=87，标准化组 N=141）为抑郁结果分析提供了数据。
结果
在基线时，量身定制组 PHQ-9 完成的可能性较低（优势比 [OR]=0.28，95%CI=0.08–0.96），但在 5 个月时更高（OR=3.39，95%CI=1.00–11.48）。两个实施组在完整的 MBC 保真度方面没有差异。PHQ-9 评分从基线（均值±标准差=17.6±4.4）显著下降到 12 周（均值=12.6±5.9）（p<0.001），但实施组或 MBC 保真度都没有显著预测第 12 周的 PHQ-9 评分。
结论
与标准化实施相比，量身定制的 MBC 实施在 PHQ-9 完成方面表现更好，但在临床医生-患者会议中讨论 PHQ-9 评分的情况仍然不理想。MBC 保真度不能预测第 12 周的抑郁严重程度。MBC 可以为协作调整会议或治疗计划提供重要信息，但可能需要更具战略性的系统级实施支持或更长的实施期。
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