Background. Depression is a highly prevalent mental health disorder that carries a heavy disease burden and is the 2nd leading risk factor for suicide among Veterans. VA has disseminated three effective psychotherapies for depression to VA clinics but therapist use of these treatments is <12%. Surprisingly, no studies have examined the provision of evidence-based psychotherapies for depression (D-EBPs) in VA and reasons underlying infrequent delivery, leaving a critical gap in depression care delivery in VA. System factors are a known driver of EBP use, and early signs from OMHSP's efforts and unique factors related to how depression care is organized in VA warrant an empirical investigation. Significance. Low utilization of D-EBPs and the lack of empirical evidence on barriers is a significant problem for several reasons. First, suicide prevention is a top priority in VA and across the nation and untreated depression is a major risk factor for suicide. Second, effectiveness of existing interventions that target provider-level barriers cannot be maximized without data about system barriers. Increasing the reach of other EBPs (e.g., PTSD) has required intervention at all levels (patient, provider, and system) and the same is undoubtably true for D-EBPs. Identifying and targeting system factors and exploring therapist factors and conducting the first exploration of patient perceptions of D-EBPs will bolster these early provider-focused interventions. Furthermore, this proposal is timely in that it comes on the heels of OMHSP's shift from assessing anticipated barriers to D-EBP delivery during trainings to developing partnerships to understand barriers experienced in the field. Finally, since this proposal is examining D-EBP delivery in specialty mental health clinics where other mental health conditions are treated, findings have implications of EBPs for those other conditions. Innovation/Impact. The proposed 3.5-year study will be the first study to examine reasons for low utilization of depression EBPs by therapists in VA. Our mixed-methods approach will yield a robust understanding of how the policies, resources and culture within specialty mental health clinics contribute to low D-EBP use by therapists. Our aims are directly aligned with OMHSP's goal to increase the implementation of clinical practice guideline-concordant care in VA mental health clinics. Our proposed classification of all VA medical centers on system-level factors that are associated with D-EBP delivery, strategic qualitative analysis, intervention mapping and stakeholder engagement provides invaluable data to OMHSP and the field quickly. Aims. 1) Quantitatively examine the association between health system factors and D-EBP delivery; 2) Qualitatively examine how contextual and system factors impact therapist decisions around the provision of D-EBPs; 3) Develop a framework of intervention targets and potential solutions to reduce barriers to D-EBP use; 4) Secondary/Exploratory Aims: a) Qualitatively explore how therapist factors impact D-EBP use; b) Explore patients' perceptions of D-EBPs. Methodology. Using an explanatory sequential mixed-method design, in Aim 1 (quantitative) we will abstract system-level and EBP training data for FY21 Q3-FY22 Q2. Descriptive statistics of system-level factors and general linear mixed model analysis will be used to characterize facilities and examine associations between system factors and therapists' D-EBP use. This will enable us to quickly understand both the main correlates of D-EBP utilization and variability of these factors across sites, provide critical data to our OMHSP partners and inform selection of sites for Aim 2. Aim 2 and secondary aims (qualitative) will include interviews with therapists trained in the three D-EBPs and mental health leaders from 10 VA medical centers (5 high and 5 low performers; N = 120- 150) and 20 patients to understand their perceptions of D-EBPs. Aim 3 will involve intervention mapping and Delphi strategies to develop a framework for reducing system barriers to D-EBP delivery. Implementation. Findings from our intervention framework development and strong partnership with OMHSP will maximize the translation of study findings into practice.

Effective psychotherapies for depression are available in VA but are underutilized by therapists working in specialty mental health clinics. Reasons for low use have not been empirically investigated. Findings from research on the implementation of evidence-based psychotherapies for other conditions such as PTSD cannot be fully generalized to depression because depression care is organized differently in VA. In this project, we use an explanatory sequential mixed-methods approach to examine contextual and system factors that impact delivery of evidence-based psychotherapies for depression as well as explore the impact of potential therapist- and patient-level factors. Findings will inform an intervention framework that will help our partners and stakeholders in the field to prioritize barriers on which to intervene and identify promising solutions.