(PS3-A1) Factors Impacting Clinical Decisions for Referral of Psychotherapies for Depression

Depression affects 14% of Veterans returning home from Iraq and Afghanistan and is a common mental health diagnosis, second only to PTSD (Tanielian & Jaycox, 2008). Given this, the VA has invested in rolling out a range of psychotherapies for depression including CBT-D, ACT-D, and IPT (Karlin et al., 2012; Karlin & Cross, 2014; Walser, Karlin, Trockel, Mazina, & Taylor, 2013). Additionally, the Manhattan VA has made specific efforts to make evidence-based psychodynamic psychotherapies for depression available (Chen, Ingenito, Kehn, Nehrig, & Abraham, 2017; Chen, Nehrig, Wash, & Wang, 2020). Mental health clinicians strive to provide depressed Veterans with the treatment that best aligns with their needs, psychosocial factors, and symptoms and individual characteristics. It is hoped that clinicians use their understanding of the patient to match them with the treatment that can most likely lead to successful outcomes and avoid client drop-out, non-compliance with treatment recommendations, or non-response. While this triaging of patients is a common aspect of clinical practice, little is known about how clinicians make these decisions.

Within this quality improvement project, we aim to understand the factors that mental health providers deem as pertinent in determining which type of psychotherapy treatment is most appropriate for patients with depression. Participants were seven senior doctoral level psychologists working in major NYC hospitals who were heavily involved in overseeing the referral process to various psychotherapy treatments for depression (e.g. clinic directors, psychotherapy training program directors, etc.). Participants were contacted and asked to identify factors they believe would make a patient successful/unsuccessful in the following evidence based psychotherapies for depression: Dynamic Interpersonal Therapy (DIT), Cognitive Behavioral Therapy for Depression (CBT-D), Behavioral Activation Therapy (BA), Acceptance and Commitment Therapy for Depression (ACT-D), or Long-Term Dynamic Therapy.  The researchers divided participant responses into categories and identified overarching themes and the factors that clinicians use to triage patients into various treatments for depression. These factors included: patient preference, ability/willingness to engage in structured treatment, display of cognitive inflexibility, patient framing of presenting problem, ability to observe and articulate inner experiences, ability to connect psychological experiences with external circumstances, ability to form positive relationships, lack of meaningful or pleasurable activities, clarity about values or goals, ability to cope with psychosocial stressors, presence of risk factors, and presence of developmental traumas.

Future research will examine the use of these factors in clinician decision making among providers referring Veterans with depression to various psychotherapists at the VA NY Harbor Healthcare System and the factors association with Veteran outcome. The findings may improve Veterans outcomes by empirically identifying factors most relevant for referral to various psychotherapy treatments for depression.