Table 1.

Qualitative Differences Between the BHL=Behavioral Health Laboratory, TIDES=Translating Initiatives for Depression into Effective Solutions, and Collocated Care Models

Depression Care Improvement Model Dimension	Description of the Dimension by Each of the Three Depression Care Improvement Models
Goals	• The TIDES initiative aimed at increasing detection and treatment completion among depression screen positive veterans in primary care through support from a depression care manager.
	• BHL focused on serving as an organized mental health assessment and triage laboratory as a gateway to diverse services, including collaborative telephone care management and mental health specialty care.
	• Collocated care focused on increasing convenient access to mental health specialty services for patients with mental illness in primary care. It served as a change agent to begin redirection of primary care processes around mental health care.
Program Development History	• Between 2001 and 2005, TIDES engaged three VA multistate regional networks and six of their primary care practices in strategic plan-do-study-act cycles to develop specifications and training for the TIDES program in an evidence-based quality improvement approach. 31,32,61 In about 2004, the model began to spread spontaneously.
	• BHL was developed in the late 1990s as a disease management program at a single site and was tested in randomized trials in a single site in one VA regional network.33–35,39 BHL focused on laboratory-specific software that enabled sophisticated algorithm-based telephone assessment by a health technician, with referral of appropriate patients to a care manager. In about 2005, the model began to spread spontaneously.
	• Collocated care began to spread beginning in the early 1990’s, but did not imply a specific program. The White River Junction collocated collaborative care model54,55 was developed over more than a decade during the late 1990’s and early 2000s within a single mental health/primary care practice setting in Vermont, but was not designed for spread.
Specific Focus on Depression Versus General Focus on Primary Care Mental Health Integration	• TIDES focused specifically on enhancing outcomes for the population of primary care veterans screening positive for depression, using a stepped care model.10
	• BHL and collocation focused on patients screening positive for depression or other common primary care disorders, including substance abuse, post-traumatic stress disorder, or anxiety.
Assessment and Triage of Referred Patients	• TIDES and BHL used standardized assessment instruments and triage protocols for all patients covering major depression, dysthymia, suicidality, post-traumatic stress disorder, substance abuse, and anxiety. These models also assessed prior mental health history and knowledge. TIDES additionally assessed patient treatment preferences, education, and family involvement.
	• BHL used health technicians or nurses or pharmacists for initial assessment; TIDES used Registered Nurse (RN) or Master of Social Work (MSW) care managers.
	• Collocated care uses mental health specialist expertise to assess and triage patients.
Follow-Up of Depressed Patients	• TIDES and BHL care managers followed patients using a standardized protocol and outcome assessment instruments. TIDES particularly emphasized support for management of depressed patients in primary care with referral to mental health specialty for patients with specific indications.
	• Collocated care uses mental health specialist expertise to guide follow-up.
Patient Self-Management Support	• TIDES and BHL guided patient self-management based on specific training and tools.
	• Collocated care used mental health specialist expertise.
Telephone versus In-Person Support	• TIDES and BHL were primarily carried out by telephone.
	• Collocated care was primarily carried out through in-person visits.
Mental Health Specialty Supervision	• TIDES and BHL care managers required mental health specialty supervision of care managers at least weekly. BHL integrated psychiatrists into ongoing supervision of laboratory activities on a more continuous basis.
Availability of Program Tools and Training	• Both TIDES and BHL, but not collocated care, were associated with accessible tools, training, and program support for practices choosing to implement them.
Information Technology	• TIDES used standard VA electronic medical record tools that were specifically redesigned to support depression care managers and their links to primary care clinicians. BHL used purpose-built software approved for use in VA but not linked to or supported by the VA information technology.
Model Complexity and Its Demand on PC Practices	• Less complex: Collocated care required space in primary care and availability of a mental health specialist, but no other major changes in how care was delivered.
	• Complex: BHL required organization of a laboratory including installation of software and creation of an organizational unit including mental health specialist(s), health technicians, and/or nurses or pharmacists. The software was maintained centrally by the original BHL developers and required little local information technology support.
	• Complex: TIDES required substantial engagement of local primary care clinicians and mental health specialists in supporting the care management approach. TIDES also required involvement of VA information technologists because it relied on adaptations based on standard VA electronic medical record tools that required local installation and updating.