Effect of Adding a Work-Focused Intervention to Integrated Care for Depression in the Veterans Health Administration: A Randomized Clinical Trial

IMPORTANCE: Thousands of working-age veterans with depression experience impaired occupational functioning. OBJECTIVES: To test whether the Veterans Health Administration (VHA) integrated care (IC) program combined with telephonic work-focused counseling, known as Be Well at Work (BWAW), is superior to IC alone for improving occupational functioning and depression, to determine whether these effects persist 4 months later, and to determine whether the return on investment is positive. DESIGN, SETTING, AND PARTICIPANTS: In this randomized clinical trial conducted from October 21, 2014, to December 6, 2019, patients undergoing IC at VHA facilities were screened for eligibility and randomized to IC alone or IC plus BWAW. Blinded interviewers administered questionnaires before the intervention, immediately after completion of the intervention at month 4, and at month 8. Eligibility criteria were individuals 18 years or older who were working at least 15 hours per week in a job they had occupied for at least 6 months, were experiencing work limitations, and had current major depressive disorder or persistent depressive disorder. Exclusion criteria were individuals who could not read or speak English, had planned maternity leave, or had a history of bipolar disorder or psychosis. Data analyses were conducted from January 1, 2018, to December 6, 2019. INTERVENTIONS: Integrated care is multidisciplinary depression care involving screening, clinical informatics, measurement-based care, brief behavioral interventions, and referral as needed to specialty mental health care. Be Well at Work counseling involves 8 biweekly telephone sessions and 1 telephone booster visit after 4 months. Doctoral-level psychologists helped patients to identify barriers to functioning and to adopt new work-focused cognitive-behavioral and work-modification strategies. MAIN OUTCOMES AND MEASURES: The primary outcome was the adjusted mean group difference in changes from before to after intervention (hereafter, adjusted effect) in the percentage of at-work productivity loss, measured with the Work Limitations Questionnaire (range, 0%-25%). The secondary outcome was adjusted effect in the Patient Health Questionnaire 9-item symptom severity score (range, 0-27, with 0 indicating no symptoms and 27, severe symptoms). RESULTS: Of 670 veterans referred for participation, 287 veterans (42.8%) consented and completed eligibility screening, and 253 veterans (37.8%) were randomized. Among these 253 patients (mean [SD] age, 45.7 [11.6] years; 218 [86.2%] men; 135 [53.4%] white), 114 (45.1%) were randomized to IC and 139 (54.9%) were randomized to IC plus BWAW. At the 4-month follow-up, patients who received IC plus BWAW had greater reductions in at-work productivity loss (adjusted effect, −1.7; 95% CI, −3.1 to −0.4; P = .01) and depression symptom severity (adjusted effect, −2.1; 95% CI, −3.5 to −0.7; P = .003). The improvements from IC plus BWAW persisted 4 months after intervention (at-work productivity loss mean difference, −0.5; 95% CI, −1.9 to 0.9; P = .46; depression symptom severity mean difference, 0.6; 95% CI −0.9 to 2.1; P = .44). The cost per patient participating in BWAW was $690.98, and the return on investment was 160%. CONCLUSIONS AND RELEVANCE: These findings suggest that adding this work-focused intervention to IC improves veterans’ occupational and psychiatric outcomes, reducing obstacles to having a productive civilian life. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT02111811