Implementation and Dissemination of Cognitive Behavioral Therapy for Depression in Kaiser Permanente Hawaii: Impact and Lessons Learned


Bradley E Karlin, PhD, ABPP; Gregory K Brown, PhD; Shari Jager-Hyman, PhD; Kelly L Green, PhD; Michi Wong, PhD; Diane S Lee, LCSW, CSAC; Andrew Bertagnolli, PhD; Thekla Brumder Ross, PsyD

Abstracts from the Kaiser Permanente 2019 National Quality Conference

From Hawaii

Background: When delivered, cognitive behavioral therapy (CBT) is generally provided with low fidelity. This pilot initiative implemented a CBT approach adapted for the Kaiser Permanente system with a focus on depression and co-occurring anxiety to bridge the research-to-practice gap, with emphasis on fidelity, the therapeutic alliance, and individualization of training and treatment to enhance treatment outcomes and engagement. The initiative involved a state-of-the-art approach to competency-based training in CBT designed to establish internal and ongoing capacity to deliver CBT.
Methods: Competency-based training in CBT for depression (CBT-D) among Kaiser Permanente Hawaii mental health practitioners included training and implementation of the protocol by therapists in training, along with system implementation and sustainability supports. Evaluation of training and implementation included assessment of both therapist and patient outcomes. Changes in therapist competency in CBT were assessed by expert raters using the Cognitive Therapy Rating Scale (CTRS). Changes in depression and anxiety among patients were assessed using the Patient Health Questionnaire-9 (PHQ-9) and the Generalized Anxiety Disorder-7 (GAD-7), respectively.
Results: In the initial training cohort, 3 out of 14 therapists demonstrated minimum competency in CBT at baseline. At the end of CBT training, 14 out of 14 therapists reached competency. In the second training cohort, 0 out of 11 therapists demonstrated competency in CBT. At the end of CBT training, 11 out of 11 therapists reached competency. Among patients enrolled in the initial training cohort (n = 36), there were statistically and clinically significant decreases in depression and anxiety symptoms from pre- to posttreatment.
Discussion: Although CBT is highly recommended in clinical practice guidelines, few therapists exhibited minimum CBT competency at the start of training. At the end of training, all therapists demonstrated CBT competency (and improvements in general therapy skills), providing support for the utility and effectiveness of this competency-based training approach. The implementation of CBT-D by therapists in training was associated with clinically significant reductions in depression and anxiety among patients. Findings provide additional support for training in and implementation of CBT in health care systems. Limitations of this program included lack of a control group, given the nature of the project as an effectiveness evaluation within a real-world treatment setting, and the relatively small numbers of participants. Next steps include focus on CBT-D sustainability and sharing of learnings and resources to promote spread to other regions.

Abstracts from the Kaiser Permanente 2019 National Quality Conference


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