Increasing uptake of depression screening and treatment guidelines in cardiac patients: a behavioral and implementation science approach to developing a theory-informed, multi-level implementation strategy

Abstract

Background

Depression leads to poor health outcomes in coronary heart disease (CHD) patients. Despite guidelines recommending screening and treatment of depressed CHD patients, few patients receive optimal care. We applied behavioral and implementation science methods to (i) identify generalizable, multi-level barriers to depression screening and treatment in CHD patients and (ii) develop a theory-informed, multi-level implementation strategy for promoting guideline adoption.

Methods

We conducted a narrative review of barriers to depression screening and treatment in CHD patients (i.e., medications, exercise, cardiac rehabilitation, and/or therapy) comprising data from 748 study participants. Informed by the Behaviour Change Wheel framework and Expert Recommendations for Implementing Change (ERIC), we defined multi-level target behaviors, characterized determinants (capability, opportunity, motivation), and mapped barriers to feasible, acceptable, and equitable intervention functions and behavior change techniques to develop a multi-level implementation strategy, targeting healthcare systems/providers and patients.

Results

We identified implementation barriers at the system/provider level (e.g., Capability: knowledge; Opportunity: workflow integration; Motivation: ownership) and patient level (e.g., Capability: knowledge; Opportunity: mobility; Motivation: symptom denial). Acceptable, feasible, and equitable intervention functions included education, persuasion, environmental restructuring, and enablement. ERIC strategies included learning collaborative, audit, feedback, and educational materials. The final multi-component strategy (iHeart DepCare) for promoting depression screening/treatment included problem-solving meetings with clinic staff (system); educational/motivational videos, electronic health record reminders/decisional support (provider); and a shared decision-making (eSDM) tool with several functions for patients, e.g., patient activation, patient treatment selection support.

Conclusions

We applied implementation and behavioral science methods to identify implementation barriers and to develop a multi-level implementation strategy for increasing uptake of depression screening and treatment in CHD patients as a use case. The multi-level implementation strategy will be evaluated in a future hybrid II effectiveness-implementation trial.

Introduction

Depression is more common amongst patients with CHD than in the general population,^1,2 and up to three times more common in patients with acute myocardial infarction (AMI)^3,4. Depression in CHD patients leads to poor health outcomes, reduces the quality of life, and poses a risk factor for MI recurrence and mortality.^5–7 A meta-analysis found that depression doubled the risk for cardiovascular disease and mortality in CHD patients.⁸

As such, expert groups, including the American Heart Association (AHA), developed several guidelines recommending screening and treatment of depression in CHD patients.^1,2 These recommendations are supported by meta-analyses demonstrating that depression treatment (e.g., antidepressants, cognitive behavioral therapy) improves patient-centered outcomes such as depressive symptoms and quality-of-life in cardiac patients.^9,10 Despite decades of epidemiologic studies and clinical trials, patients with depression and CHD are seldom approached by their physician for depression treatment, with recent estimates as low as 6.6% undergoing psychotherapy and 4.1% medication therapy.¹¹ To date, multi-level (i.e., system/provider and patient) barriers to treatment uptake have not been systematically reviewed, resulting in a shortage of theory-informed depression treatment implementation trials in cardiac populations. Guideline implementation also requires changing behavior at multiple levels, which is particularly challenging in specialty sites.

Implementation Science (IS) is the scientific study of methods to promote the equitable and systematic uptake of evidence-based interventions into healthcare practice and policy.¹² IS relies heavily on theoretical frameworks, to elucidate barriers and facilitators (determinants) to guideline uptake. This study had two goals: First, to systematically identify multi-level (at the system/provider and patient level) barriers and facilitators of depression screening and treatment in patients with CHD, and second, to develop a multi-level implementation strategy to increase the uptake of depression screening and treatment guidelines in clinical sites caring for CHD patients.

Method

Study overview

We used behavioral and implementation science methods to develop a multi-level implementation strategy for promoting depression screening and treatment in cardiac patients. First, we conducted a narrative literature review to identify barriers and facilitators of the target behavior, i.e., depression screening and treatment in patients with CHD. Second, we applied a multi-step framework for developing a multi-level implementation strategy to increase the uptake of depression screening and treatment guidelines, targeting healthcare systems/staff, providers (i.e., cardiologists, PCPs: primary care physicians) and patients concurrently. Third, we engaged stakeholders in adapting the implementation strategy to our local context (Figure 1).

Figure 1.

Summary of the development process of the implementation strategy.

This study did not require Institutional Review Board (IRB) approval. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Study Population

Based on AHA and other clinical practice guidelines,^1,2 this study focuses on the target behavior (i.e., depression screening, referral, and treatment) among two target populations: (i) providers of primary care and general cardiologists and (ii) CHD patients.

Phase 1. Narrative literature review of barriers and facilitators

We conducted a narrative review to identify barriers to and facilitators of depression screening and treatment in patients with CHD. We searched three databases (PubMed, CINAHL, and PsycInfo). We supplemented the three database searches with additional searches of Google Scholar. The complete search strategies for each database are included in Supplementary Table 1. Eligible records had to describe original/empirical research, be written in the English language and published in the past 20 years, assess barriers to and facilitators of depression screening and/or treatment, and focused on cardiac patients (defined as patients with heart attack, MI, cardiovascular disease, CHD, heart disease, vessel disease), be applicable to outpatient sites (inpatient data were included if relevant to outpatient sites), and provide qualitative or mixed-methods data. Two independent reviewers (KR, KG) conducted the eligibility screening of titles/abstracts and full-text articles. Any discrepancies were discussed and resolved among the three authors (KR, KG, NM).

Phase 2. Development of multi-level implementation strategy

Theoretical framework and procedures: We used the Behaviour Change Wheel (BCW),^13,14 a multi-step behavioral and implementation science framework, to guide the development of a multi-level strategy for improving behaviors related to depression screening, referral, and treatment at the system/provider and patient level in outpatient sites. The framework has been extensively used to create implementation strategies.^15–21 Our work was informed by a literature review on depression screening and treatment in cardiac patients described above and prior work designing a multi-level implementation strategy for sustaining collaborative care for depression in primary care sites (also centered around an electronic shared decision making tool and provider education).²² Two members of the team with training in the BCW framework (KR, NM) linked barriers (e.g., lack of knowledge) to intervention functions (e.g., education, environmental restructuring) to bring about system/provider-level and patient-level change.

Step 1–4: Understand the behavior

The focus on depression screening, referral, and treatment in CHD patients was informed by previous AHA guidelines.^1,2 We used the BCW framework to define, select, and specify key behaviors in terms of what needed to change on the parts of the healthcare system, provider, and patient separately to enable depression screening, referral, and treatment in outpatient sites, respectively. We considered healthcare system level behaviors to be related to clinical administrators and staff (e.g., depression screening). The BCW framework centers on the fact that changing behavior requires increasing Capability (e.g., knowledge), Opportunity (e.g., resources), and/or Motivation (e.g., self-efficacy) for a behavior (COM-B model)¹ by removing barriers and/or augmenting facilitators to the target behavior that is crucial to the implementation of evidence-based interventions (i.e., depression screening, treatment referral). Team members categorized barriers into capability, opportunity, and motivation constructs. Barriers at the healthcare system and provider level were categorized together, given their conflation in the literature.

Steps 5–6: Identify intervention options

We then mapped the identified COM-B model constructs above to nine corresponding intervention functions (e.g., training and education interventions would address capability deficits). The intervention functions are further enriched by seven policy categories (Supplementary Figure 1). These categories are broader population-level strategies that enable the intervention functions (e.g., communication/marketing, guidelines, fiscal measure, regulations, legislation, environmental/social planning). For example, they might support the design and/or control of the physical or social environment, and service provision. The BCW framework calls for using the APEASE criteria (Affordability, Practicability, Effectiveness and Cost-Effectiveness, Acceptability, Side-effects and Safety, Equity) to direct the selection of appropriate intervention components, content, and implementation options.¹³ We selected those intervention functions and policy categories that met all of the APEASE criteria and might help deliver the intervention.

Steps 7–8: Identify content and implementation options

We then mapped intervention functions to behavior change techniques, defined as active components of interventions designed to achieve observable and replicable behavior change.¹³ A taxonomy of behavior change techniques corresponds to intervention functions (e.g., education interventions can be delivered by instruction on how to perform behaviors or prompts and cues).¹³ We selected those behavior change techniques that met all of the APEASE criteria.

Phase 3. Adapt and finalize multi-level implementation strategy

Adaptation to local context

We selected only those intervention functions, policy categories, and behavior change techniques that met the APEASE criteria as they related to eight clinical sites of racially, ethnically, and socioeconomically diverse primary care and cardiology clinics at the New York Presbyterian Hospital/Columbia University Irving Medical Center (Example of a related key question: Would all our sites and patient populations find an educational intervention acceptable and practical?). Half of the clusters of sites (n= 4/8) have an embedded collaborative care program and half have traditional mental health referral systems. To adapt to the local context, a group of stakeholders reviewed and operationalized the proposed implementation strategies.

Between from August 30, 2018, and July 21, 2021, researchers met with multidisciplinary teams of stakeholders (both in group and one-on-one meetings): (1) a user experience team, including a creative director, developers, and user experience experts to operationalize and adapt system-, provider-, and patient-facing materials; (2) an intervention development team including PCPs, cardiologists, cardiac nurse practitioners, racial/ethnic minority patients with CHD, psychologists and depression care managers who ensured fit of the implementation strategies to the contexts in diverse clinical sites; (3) an advisory board of members with expertise in behavior change and patient activation to refine the strategy; and (4) CHD patients who tested interventions components (the patient usability protocol and results will be described separately). The goal was to maximize the usability, safety, feasibility, and sustainability of our multi-component strategy in a variety of clinical sites with varying resources (e.g., with and without collaborative care programs). We engaged at least one clinic administrator or medical director and at least one mental health provider at each site slated for intervention to review and deliver the intervention materials. The user experience and advisory board members involved in this project also adapted implementation strategies for multiple other mental health use cases (e.g., sustaining collaborative care models). The detailed stakeholder engagement and adaptation approach is described in a separate manuscript.²²

Finalization of implementation strategy

At the end of the mapping process, we distilled the behavior change techniques into Expert Recommendations for Implementing Change (ERIC) strategies to answer expert calls for ensuring the use of shared language when designing implementation strategies, allowing for comparisons across studies in the field.²³ While system and provider levels were combined to correspond with the qualitative data, we separated our final multi-component strategy by the level in which the component was intervening (i.e., system, provider, or patient).

Results

Results Phase 1: Narrative review of barriers and facilitators

We examined barriers to depression screening and treatment in cardiac patients. Our literature search resulted in 199 records. Of those, 15 were removed through deduplication, using RefWorks. Of the 184 records we screened for inclusion in the analysis, 13 were eligible and further analyzed (Supplementary Table 2). Only 2 out of 13 studies from the same study team focused on multi-level approaches.^24,25 The included studies comprised a total of 748 study participants (540 patients/service users, 205 health professionals, 3 caregivers) (Figure 2).

Figure 2.

PRISMA diagram illustrating the data identification, screening, and inclusion process.

(All databases searched on Jan. 27, 2022)

Adapted From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ 2021;372:n71. doi: 10.1136/bmj.n71

Based on the narrative review, we identified barriers that might impede depression screening and treatment at the system/provider and CHD patient level (Table 1). Because the literature often conflated screening and referral, healthcare system/staff- and provider-level, these barriers are presented together.

Table 1.

Behavioral specification of the multi-level target behavior at the (i) system, (ii) provider level, and (iii) patient level.

Target behavior	System level	Provider level	Patient level
Who needs to perform the behavior?	Clinic staff	Healthcare professional, e.g., cardiologist, primary care physician	Patient with CHD
What do they need to do differently to achieve the desired change?	Screen for depression	Refer/optimize treatment (therapy/cardiac rehabilitation, titrate/add/initiate antidepressants)	Initiate/optimize treatment (attend psychotherapy or cardiac rehabilitation visits and/or adhere to medications)
When do they need to do it?	At patient encounter	During scheduled doctor appointment	After diagnosis and referral
Where do they need to do it?	Clinic, hospital	Clinic, hospital	Clinic, hospital, virtual/home
How often do they need to do it?	Annual screen, screen following hospitalization for an acute cardiovascular event	As needed based on severity of patient’s symptoms	As needed based on severity of patient’s symptoms, patient preference and treatment availability
With whom do they need to do it?	CHD patients with elevated depressive symptoms	CHD patients with elevated depressive symptoms	Healthcare professional (e.g., cardiologist, primary care physician)

Determinants of depression screening/treatment at the system/provider level

We found several barriers related to attention and decision processes at the system/provider level. Providers lacked time to conduct the screening and initiate a referral, dealing with competing priorities (e.g., “Too many things to pay attention to”).^26,27 They also lacked critical knowledge to recognize depression and its connection to cardiovascular diseases. ^26,27 For nurses, in particular, we identified a lack of the ability to approach doctors and effectively discuss with patients and their families the implications of identifying signs of depression and possible referral avenues,²⁷ including situations that required evidence-based, sociocultural, and health literacy-adapted resources (e.g., bilingual educational materials, clinical social worker, and community patient navigator).²⁸ The need for a formal, standardized screening tool was also reported (e.g., “Order sets not always on chart”, “Sometimes sticker is missed”, “Multiple steps make it difficult”), clinical directions for different depressive symptom classifications (e.g., “Consider better guidance on what to do for different PHQ scores”), and support and integration of depression screening and referral into the existing workflow (e.g., “Make psychiatry referral automatic for positive screens,” “Consider including the screening as a part of the chart audits for other documentation issues”).^26,27 Finally, barriers mentioned by system/providers included the disbelief in their ownership and responsibility of the process (e.g., “I wonder if we were stepping on toes of PCPs”, “Should they see a psychiatrist in the hospital, follow up with their PCP or psychiatrist or should I give them an antidepressant?”), feeling unqualified (e.g., “Not sure cardiologists are qualified to treat depression”), disbelief in their ability to effectively address patients (e.g., “Older people get upset,” “Patients are overwhelmed already”), and a lack of reinforcement and feedback to sustain interest in the process and behavior (e.g., “Need follow-up education”).²⁶ System/providers considered the patients’ lack of intrinsic motivation and need to improve depressive symptoms as a barrier.²⁴

Determinants of depression screening and treatment at the patient level.

For CHD patients, we identified the lack of knowledge about depression, its connection to cardiovascular diseases, and mental health care possibilities (e.g., “You don’t know what is normal, how you’re supposed to feel,” “I needed information badly but nobody talked to me.”).^{25–27,29–31} Furthermore, a lack of mobility was also reported (e.g., “Your ability to travel is inhibited … getting on and off public transport in the city is pretty daunting”) or receiving the referral at a time when the patient can take the necessary steps (e.g., “It was nearly three weeks before I got out of bed. Before I could even think of it.”).²⁹ We also found a lack of financial means as physical barriers (e.g., “Your ability to travel is inhibited … getting on and off public transport in the city is pretty daunting […], I would be there for maybe 30 minutes and it was a cost of about $195 […] I didn’t think it was worth it financially”).³² Finally, for CHD patients, we identified a lack of peer support opportunities (e.g., “Have groups of um heart patients that can get together and talk about the mental side of it”), a lack of a personal connection and comfort to discuss their mental health problems with system/providers,^29–33 and mentioned a lack of belief in the validity of screening instruments and the denial of depression symptoms (e.g., “I’m not depressed.”).^25,32–33

Results Phase 2. Multi-level implementation strategy

Steps 1–4. Specification of the target behavior

Based on guidelines^1,2 and the findings from the narrative review, we defined the behavioral targets to be the screening of depression, referral, and treatment initiation in CHD patients. We determined that healthcare systems/providers are required to screen for depression and optimize treatment (e.g., refer depressed patients with CHD to therapy), and patients must initiate and adhere to psychotherapy, cardiac rehabilitation/exercise program, and/or medications.

Then, we categorized barriers that might impede the target behavior into corresponding COM-B constructs (capability, opportunity, and motivation), which is presented in Table 2. Overall, our behavioral diagnosis (Figure 3) indicated that to address multi-level barriers and achieve the target behavior of improving depression screening and treatment referral, change in psychological capability (e.g., knowledge to recognize depression, how to discuss positive screens), physical opportunity (e.g., lack of time, socio-culturally adapted mental health resources, standardized protocols, alignment with workflow), and reflective and automatic motivation (disbelief in ownership, ability, qualifications), would be needed. For CHD patients, we found indicators of need for change in psychological capability (e.g., literacy, lack of knowledge about depression and CHD), physical opportunity (e.g., mobility, finances), social opportunity (e.g., stigma, peer support), and reflective motivation (e.g., symptom denial and screening validity).^25,32–33

Table 2.

Applying the COM-B model to the determinants of depression screening and treatment initiation to identify what needs to change and potential intervention functions at the system/provider level and patient level for the target behavior to occur.

COM-B component	Barriers to improving depression screening and treatment initiation		Potential intervention function
	System/Provider	Patient
Psychological capability	Lack of knowledge about depression and its relationship with cardiovascular diseases, lack of awareness of mental health care possibilities	Lack of awareness of depression and its relationship with cardiovascular diseases, lack of knowledge of mental health care possibilities	● Education ● Training
	Lack of skills to conduct screening	-
	Lack of knowledge/skills on the parts of nurses/staff to approach doctors and effectively discuss with patients and their families depression and possible referral avenues, including language skills	-
Physical opportunity	Lack of formal, standardized screening tool	-	● Training ● Environmental restructuring ● Enablement
	Lack of clinical directions for different depressive symptom classifications	-
	Lack of support and integration in existing workflow, e.g., visibility of protocol automatic psychiatry consult for positive screens, screening as part of clinical review consultation	-
	Lack of sociocultural, health literacy-adapted educational and community resources to refer patients to	Lack of resources that meet the patient’s cultural, lingual, and health literacy needs	● Education ● Enablement
		Lack of mobility (transport limitations), timing of referral	● Environmental restructuring ● Enablement
	Lack of time and resources, competing priorities	Lack of financial means	● Environmental restructuring ● Enablement
Social opportunity	-	Lack of peer support opportunities	● Environmental restructuring ● Modeling ● Enablement
	-	Lack of a personal connection with provider and discomfort discussing their mental health problems
Reflective motivation	Lack of belief in ownership/responsibility about process	-	● Education ● Persuasion ● Modeling
	-	Lack of acknowledgement of depression (and experienced stigma)
	Lack of belief in benefits of healthy behavior	-
	Lack of belief in ability/qualification to effectively address patient needs and conduct screening	-	● Education ● Persuasion ● Modeling ● Enablement
	-	Lack of belief in validity of screening instruments	● Education ● Persuasion ● Modeling
	Disbelief in patients’ intrinsic motivation and need to improve depressive symptoms	-
Automatic motivation	Lack of reinforcement and feedback to sustain interest in the process/behavior	-	● Training ● Incentivization ● Environmental restructuring

Abbreviations: X: “applies”, - “does not apply; COM-B Capability, Opportunity, Motivation-Behavior Model

Figure 3.

Using the Capability (e.g., knowledge), Opportunity (e.g., resources), and/or Motivation (e.g., self-efficacy) for a behavior (COM-B) model to understand multi-level barriers to the target behavior (i.e., depression screening and treatment) in coronary heart disease patients, focus on outpatient sites. *Categories notable for providers and coronary heart disease patients, respectively.

Steps 5–6. Identification of intervention functions and policy categories

After we determined the relevant COM-B components that would require change, we identified corresponding intervention functions that would promote system/provider and patient level adoption of depression screening, referral, and treatment (Supplementary Table 3).

System/provider level:

Informed by the APEASE criteria mentioned above, we determined that intervention functions at the system/provider level would include environmental restructuring (e.g., changing the physical or social context via electronic health record [EHR]-facilitated screening and referrals), training (e.g., teaching staff proper screening and providers how to refer/treat), education (e.g., provide knowledge on relationship between heart disease and depression), persuasion/ modeling (e.g., providing an example for people to aspire to or imitate such as a cardiologist referring patients to mental health with activating/persuasive patient stories), and enablement (e.g., increasing means and reducing barriers to increasing capability or opportunity through bypassing providers using automatic referrals) (Table 3, Supplementary Table 3). Several intervention functions did not meet all the APEASE criteria. For example, coercion (i.e., creating an expectation of punishment or cost around screening and treatment) was not deemed affordable, acceptable, safe, or equitable (i.e., disproportionately affecting disadvantaged groups with less power). Corresponding policy categories to enable these intervention functions included communication/marketing (e.g., promoting depression screening using print, electronic, telephonic, or broadcast media) and environmental/social planning (e.g., designing and/or controlling the EHR or community mental health environment). Service provision (e.g., having a navigator facilitate all screening, referral, and treatment) was not deemed affordable. Fiscal measures, legislation and/or regulation-related policies (e.g., making depression screening/treatment in CHD patients a publicly reported measure of quality of care or having insurers pay for depression screening or withholding payment if recently hospitalized CHD patients not screened) were deemed effective but not practical to spearhead at the clinical system/provider level in our settings but perhaps at the payor level (Table 3, Supplementary Table 3).

Table 3.

Operationalizing a multi-component implementation strategy for improving depression screening and treatment in CHD patients. Included are behavioral change techniques (BCTs), intervention functions, COM-B constructs, delivery mode, and implementation science (IS) outcomes.

Actor	BCTs	Intervention function	COM-B constructs					Tactics	Delivery Mode DOSE IS targeted outcome	Adapted delivery mode (e.g., due to COVID19)
			PC	SO	PO	RM	AM
System/Provider	Demonstration of the behavior: provide an observable sample of the performance of the behavior, directly in person or indirectly, e.g., via film, pictures, for the person to aspire to or imitate (includes modeling)	Training, Modeling	X	X	X	X	X	Provide content, e.g., clinical case/pictures demonstrating staff/provider screening, ordering and referral, showing an example of an ideal note	Grand Rounds ONCE AND ON-DEMAND Acceptability	Onboarding video delivered via clinic director or team member in newsletter or email with or without virtual presentation
	Instruction on how to perform a behavior: advise or agree on how to perform the behavior (includes skills training)	Training	X		X		X	Educational content (e.g., tutorial, step-by-step checklist, how-to infographic) about ordering/referring depression screening and treatment Demonstrate to provider how to broach issue of managing stress/depression with CHD patients	Grand Grounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter or email with or without virtual presentation
	Feedback on behavior: monitor and provide informative or evaluative feedback on performance of the behavior (e.g., form, frequency, duration, intensity)	Training Education Persuasion Incentivization	X		X	X	X	Feedback to providers on rates of screening, appropriate referrals	EHR dashboards; Align with Accountable Care Organization reports QUARTERLY TO ANNUALLY Acceptability, fidelity, feasibility, sustainability	Email notifications to providers; during virtual meetings with physical/mental health providers
	Adding objects to the environment: add objects to the environment in order to facilitate performance of the behavior	Environmental restructuring Enablement	X	X	X		X	Add iHeart DepCare eSDM tool elicited summary report of patient preferences and treatment recommendations	Summary Report of eSDM tool via email notification ONCE/PATIENT Acceptability, usability, fidelity	Summary report via email and Epic inbox/messaging
	Prompts and cues: introduce or define environmental or social stimulus with the purpose of prompting or cuing the behavior. The prompt or cue would normally occur at the time or place of performance	Environmental restructuring Education	X	X	X	X	X	- Enable point-of-care screening and referral reminder in EHR; enable automatic referral support when patient screens positive eSDM tool elicited summary report/decisional support to cue referral and treatment by cardiac and mental health providers	EHR prompt; Summary Report of iHeart DepCare eSDM tool via email notification ONCE/PATIENT Acceptability, fidelity, adoption, feasibility, sustainability	Summary report via email and Epic inbox/messaging
	Restructuring the physical environment: Change or advise to change the physical environment in order to facilitate performance of the wanted behavior or create barriers to the unwanted behavior (other than prompts/cue, rewards and punishments)	Environmental restructuring Enablement	X	X	X		X	Enable prompts, ordersets to facilitate/guide treatment by providers	EHR ONCE Acceptability, usability, fidelity	Epic smartphrase
	Problem solving: Analyze, or prompt the person to analyze, factors influencing the behavior and generate or select strategies that include overcoming barriers and/or increasing facilitators	Enablement	X	X	X		X	Review screening, referrals, initiation and barriers to implementation to brainstorm areas of improvement	In-person meetings among implementation team/researchers QUARTERLY TO ANNUALLY Fidelity, sustainability, feasibility	Virtual meetings to include physical/mental health providers and align with existing learning health collaborative to problem solve clinic-level concerns (screening quality, implementation, wait times, etc); Email notifications to providers
	Review behavior goal(s): review behavior goals jointly with the person and consider modifying goals or behavior change strategy considering achievement. This may lead to re-setting the same goal, a small change in that goal or setting a new goal instead of (or in addition to) the first, or no change	Enablement	X	X	X		X	Review screening and referral implementation, brainstorm areas of improvement	In-person meetings among implementation team/researchers; EHR dashboard QUARTERLY Fidelity, sustainability	Virtual meetings with physical/mental health providers; email notifications
	Salience of consequences: Use methods specifically designed to emphasize the consequences of performing the behavior with the aim of making them more memorable	Enablement Persuasion	X	X	X	X	X	Educational content (e.g., utorial, talking points) to address consequences of performing the behavior (focus on improvement of CVD if stress/emotional health addressed, discuss shocking rates of depression in CHD patients)	Grand Rounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Information about social and environmental consequences: provide info (written, verbal, visual) about social and environmental consequences of performing the behavior	Education Persuasion	X			X	X	Educational content (e.g., tutorial) about social and environmental effects of performing screening and referral (e.g., improving patient satisfaction and relationships)	Grand Rounds ONCE AND ON-DEMAND Acceptability, fidelity, adoption	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Information about health consequences: provide information (e.g. written, verbal, visual) about health consequences of performing the behavior	Education Persuasion	X			X	X	Educational content (e.g., video tutorial, testimonials) about health consequences of performing screening and referral among patient population (e.g., reducing risk of future heart attack)	Grand Rounds ONCE AND ON-DEMAND GRAND ROUNDS Acceptability, fidelity	Onboarding video delivered via clinic director or team member in newsletter/email with or without virtual presentation
	Credible source: present verbal or visual communication from a credible source in favor of or against the behavior	Persuasion	X			X		Present statements by high-status professionals (e.g., clinic director) and patients themselves to emphasize the importance of screening and referral to increase the well-being of the patient population	Grand rounds ONCE AND ON-DEMAND Acceptability, fidelity, feasibility, adoption	Onboarding video delivered via clinic director or team member in virtual newsletter/email with or without virtual presentation
	Verbal persuasion about capability: Tell the person that they can successfully perform the wanted behavior, arguing against self-doubts and asserting that they can and will succeed	Persuasion Enablement	X	X	X	X	X	Educational content (e.g., tutorial, testimonials) to tell provider that they can successfully conduct the referral and thereby improve the care of their cardiac patients	Grand rounds ONCE AND ON-DEMAND Acceptability, fidelity	Onboarding video delivered via clinic director or team member in virtual newsletter/email with or without virtual presentation
Patient	Demonstration of the behavior: provide an observable sample of the performance of the behavior, directly in person or indirectly, e.g., via film, pictures, for the person to aspire to or imitate (includes modeling)	Training Modeling	X	X	X	X	X	Multilingual content, e.g., Animation, with diverse patients (including minorities) modeling engagement, talking to doctor/provider, going to treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, feasibility	Multi-modal web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Instruction on how to perform a behavior: advise or agree on how to perform the behavior (includes skills training)	Training	X		X		X	Multilingual educational content to promote patient activation (e.g., video tutorial, step-by-step checklist, how-to infographic) to manage conversation with provider about screening and referral, going to treatment, accessing/navigating preferred resources	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, feasibility
	Adding objects to the environment: add objects to the environment to facilitate performance of the behavior	Environmental restructuring Enablement	X	X	X		X	Add eSDM tool to the screening/referral process that provide multilingual information for patient activation, psychoeducation, and referral with flexible modality, and self-assessment prior to appointment with provider, including reminder to talk to provider	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, usability, fidelity	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Prompts and cues: introduce or define environmental or social stimulus with the purpose of prompting or cuing the behavior. The prompt or cue would normally occur at the time or place of performance	Environmental restructuring Education	X	X	X	X	X	eSDM acts to remind patient of importance of depression screening and treatment, talking to provider, appointment reminder (multiple language choices)	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, usability, fidelity, adoption	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Restructuring the physical environment: change or advise to change the physical environment to facilitate performance of the wanted behavior or create barriers to the unwanted behavior (other than prompts/cue, rewards and punishments)	Environmental restructuring Enablement	X	X	X		X	Provide internet-, community, home-based treatment options to restructure the mental health environment and supplement healthcare system environment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, sustainability, adoption	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about social and environmental consequences: provide info (written, verbal, visual) about social and environmental consequences of performing the behavior	Education Persuasion	X			X	X	Provide multilingual information to about social and environmental consequences, e.g., inform patient that the treatment may impact/improve social relationships	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about emotional consequences: Provide information (e.g., written, verbal, visual) about emotional consequences of performing the behavior	Persuasion	X			X		Provide multilingual information to about social and environmental consequences, e.g., explain that depression treatment increases well-being and life satisfaction	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Information about health consequences: provide information (e.g., written, verbal, visual) about health consequences of performing the behavior	Education Persuasion	X			X	X	Provide multilingual information to about health consequences, e.g., explain treatment may improve heart health	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Credible source: present verbal or visual communication from a credible source in favor of or against the behavior	Persuasion	X			X		Provide content, e.g., physician video, to emphasize the importance and positive impact of depression treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability
	Verbal persuasion about capability: Tell the person that they can successfully perform the wanted behavior, arguing against self-doubts and asserting that they can and will succeed	Persuasion Enablement	X	X	X	X	X	Provide content, e.g., animation and provider video, that the patient can successfully reduce their risk of a future heart attack if their depression gets treated	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Framing/reframing: Suggest the deliberate adoption of a perspective or new perspective on behavior (e.g., its purpose) in order to change cognitions or emotions about performing the behavior (includes ‘Cognitive structuring’)	Enablement Persuasion	X	X	X	X	X	Provide multilingual content, e.g., video, infographic, suggesting that the patient might think of, e.g., the task of depression screening and treatment as reducing the risk of another heart attack rather than mental health treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Social comparison: Draw attention to others’ performance to allow comparison with the person’s own performance	Persuasion	X			X		Provide multilingual content, e.g., animation/provide video to show the patient how patients like them improved their well-being and quality of life after depression treatment	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)
	Salience of consequences: Use methods specifically designed to emphasize the consequences of performing the behavior with the aim of making them more memorable (goes beyond informing about consequences)	Enablement Persuasion	X	X	X	X	X	Provide content, e.g., a provoking animation that demonstrates heart attack and how the patient coped afterward	iPad-delivered web-based application in waiting room ONCE, ON DEMAND Acceptability, Sustainability	Web-based application (via e.g., phone, tablet, computer); printed materials (waiting room, home/mailer)

Abbreviations: Behavior Change Techniques (BCTs), COM-B Capability, Opportunity, Motivation-Behavior; PC: Psychological capability, SO: Social opportunity, PO: Physical opportunity, PO: Physical opportunity, RM: Reflective motivation, AM: Automatic motivation; EHR electronic health record; eSDM electronic shared decision-making tool.

Patient-level:

We determined that feasible intervention functions would include training- and education-related interventions to address the knowledge gaps around validity of screeners, treatment options and recognizing depression symptoms (Table 3, Supplementary Table 3). Additionally, environmental restructuring might include the addition of tools that support treatment selection and access to free online cognitive behavioral therapy to address cost and transportation issues. Several intervention functions did not meet all the APEASE criteria. For example, we determined that incentivization (i.e., creating an expectation of reward) of treatment initiation or adherence was not deemed affordable, practical, safe, or equitable. Akin to the systems/provider-level examples above, corresponding policy categories included communication/marketing and environmental/social planning (e.g., provision of web-based therapy options) (Table 3, Supplementary Table 3).

Steps 7–8. Identification of behavior change techniques and mode of delivery

System/provider level:

To deliver the intervention functions and policy categories above at the system/provider level, we identified several corresponding behavior change techniques that met all of the APEASE criteria (Table 3). Education/Training could be delivered via demonstration of behavior (i.e., screening/referral); instruction on how to perform the behavior; feedback on the behavior; and information about social/environmental, emotional, and health consequences of the behavior. Study team members considered a key mode of delivery to be yearly grand rounds presentations by a credible source (e.g., cardiologist) describing depression in CHD patients, how to refer a CHD patient for behavioral health/start antidepressants, and consequences of referrals via patient stories. Persuasion-related behavior change techniques included verbal persuasion, use of a credible source, and salience of consequences. Providing stories of patients’ experiences after screening and referral that demonstrate how a heart attack patient dealt with depression and the impact on cardiac outcomes was considered a key method for emphasizing the consequences of performing the behavior and making them more memorable. Communication/marketing materials were branded with “iHeart DepCare” to maximize recognition and dissemination (Table 3). We determined that environmental restructuring intervention functions could be delivered via adding objects to the environment, prompts/cues, and restructuring the physical environment, e.g., point-of-care screening and referral reminders, automatic referral support when a patient screens positive to bypass providers, dashboard for feedback on screening and treatment of the behavior. The EHR was considered an essential mode of delivery, including reminders and summary reports of patient’s treatment preferences and perceived barriers to care via email to prompt referrals. Enablement-related behavior change techniques also included regular implementation of problem-solving meetings throughout the study period to review behavior goals amongst researchers (Table 3).

Patient level:

Feasible behavior change techniques for promoting depression treatment initiation and adherence included the demonstration of behavior, instruction on how to perform, information about social/environmental, emotional, and health consequences of the behavior, credible source, verbal persuasion about capability, adding objects to the environment, prompts/cues, and restructuring of the physical environment (Table 3). We operationalized the behavior change techniques by adapting an electronic shared decision-making [eSDM] meant for addressing depression in primary care settings to incorporate the unique barriers faced by CHD populations and their providers.^22,34 The multilingual patient activation/persuasion eSDM tool (iHeart DepCare)³⁴ includes a screening questionnaire and depression profile, infographics and a script by a credible cardiologist on treatment options unique to CHD patients and the importance of talking to one’s provider about stress, a CHD patient story on attending therapy and taking an antidepressant, as well as psychoeducation about the link between depression and CHD, and benefits of treatment. Salience of consequences and social comparison were achieved via a vivid story of a depressed CHD patient’s experience. Framing/reframing (e.g., deliberate adoption of a perspective or new perspective on behavior such as purpose-focused) was achieved by framing depression treatment as integral to managing one’s heart disease.

To operationalize prompts/cues and environmental restructuring, the [eSDM] tool included medication management support, access to free, web-based cognitive behavior therapy, and messaging to address individual patients’ perceived barriers to treatment (e.g., treatment cost, stigma of depression). Initially, the most feasible, acceptable, equitable, and effective mode of delivery was to deliver via an iPad in the waiting room at the time of the patient’s appointment with their cardiologists or PCP to align with providers’ workflows and ensure that all patients would be reached. Some behavior change techniques were not deemed feasible, including providing feedback on the whether a patient-initiated treatment after referral. Given concerns about unintended consequences (e.g., shame) and equity issues (might disproportionately shame patients facing more structural barriers to treatment) (Table 3).

Phase 3. Adapt and finalize implementation strategy

Adaptation to contextual factors

System level:

Given changing contextual factors and need for ongoing stakeholder engagement, stakeholders recommended adapting regular problem-solving meetings among implementation team members to include mental health providers at each site to review screening/referral goals while addressing multi-level level barriers to implementation (e.g., limited mental health resources, unique needs of depressed CHD patients such as behavioral activation, long wait times, and need for integrated care between psychiatry and medicine). One cardiology nurse practitioner in a site without collaborative care programs recommended updating the referral lists of local mental health providers as part of the problem-solving meetings. Mental health stakeholders suggested disseminating existing quality improvement screening videos to improve the screening quality in clinical sites, particularly for those CHD patients who did not access the patient portal (i.e., were screened by medical assistants). Given interest in learning health systems across the institution and need for more formal, data-driven processes, it was recommended that meetings align with existing learning mental health collaborative meetings, which would also facilitate review of screening, referral, and initiation rates and goals (Tables 3, 4).

Table 4.

Adaptation of multi-component iHeart DepCare implementation strategy to fit local context

Actor	Preliminary implementation strategy	Reasons for adaptation	Final implementation strategy
System/Staff	- Ongoing problem-solving meetings by implementation/research team	- Need for more formal, data-driven process for addressing implementation needs - Need to keep physician champions and mental health providers engaged in implementation process given rapid contextual changes during COVID19 pandemic - Continued concerned about lack of access to mental health providers, particularly those educated to treat CHD patients	- Expanded problem-solving meetings to include physical and mental health providers to address contextual determinants of implementation (e.g., brainstorm how to maximize limited resources, address wait times, incorporate behavioral activation into mental health treatment for CHD patients, update referral lists, disseminate screening quality videos to staff) - Aligned with existing Learning Mental Health Collaborative to ensure data-driven approach
Provider	- In Person Grand Rounds presentation on depression and heart disease	- Shifts to remote work during COVID19 pandemic/Concerns for low meeting attendance rates - Concerns regarding lack of low fidelity/provider adherence to educational strategy (e.g., due to lack of time, length of material) -Need for clear, brief, action- oriented language (e.g., pneumonic)	- Developed online formats (video and newsletter) for distribution of educational content - Content limited to essential, “need to know” information and task oriented (e.g., referral and treatment optimization) - Incorporated essential content within body of email/newsletter in case providers don’t click on links - Have clinic directors deliver the video/survey to improve fidelity to strategy
	- Built in prompts/cues/dashboard for referral feedback in EHR	- Concerns regarding acceptability of automated alerts via Epic, often ignored due to alert-fatigue among providers; could be viewed as overly intrusive - Lack of feasibility of creating dashboard for individual providers given competing clinic priorities during COVID19 - Concerns for overwhelming limited mental health system	- Developed “iHeart” smartphrase (i.e., “dot phrases,” that allow commonly used chunks of text to easily be inserted into patient notes”) -Email notification of feedback on clinic level referral rates, also presented during problem solving meetings
	- Summary report from eSDM tool on patient treatment preferences and optimization recommendations printed and delivered to provider during visit	-Restrictions to waiting room projects 2/2 to COVID19 -Too long/detailed, not enough information on actionable next steps for busy providers	- Adapted, shortened summary report with “recommended action” on top - Summary report delivered via email and Epic - Included cardiac health profile with feedback on health behaviors to improve usefulness and acceptability
Patient	eSDM tool with depression screening, psychoeducation (via patient and provider videos), treatment decision support with pros/cons, and review of barriers to treatment -Delivered by implementation team in waiting room via iPad	Mode of Delivery - COVID-19 pandemic required flexible delivery approach outside waiting rooms	- Shifted from focus on iPad to supporting web-based application (accessible via phone, tablet, or computer)
		Workflow - Concerns by patients that making primary care providers or cardiologists address depression, which might undermine their medical concerns - Concerns by stakeholders that bypassing providers and automatically referring patients would overwhelm the limited mental health system - Need to align with clinic-level screening efforts - Digital Literacy considerations	- Delivery of tool results to mental health navigators/ providers (in addition to primary care providers/cardiologists) and alerting patients that their results would be delivered to their physicians - Tool bypasses screening if already done by system - Included paper copy of tool for all patients; multi-modal delivery of tool components (e.g., email pdf or video)
		Content - Concern for increasing stress/anxiety by broaching heart attack - Need more education on heart disease to better engage patients - Concern that patient video about mental health may be less acceptable to mostly male CHD patients - Need for contingency plan in the case that clinicians ignore prompts/summary report	- Removed “heart attack” signs/language - Prioritized depression treatment/maintenance/outcomes vs. education on the heart disease. - Added content hub at end of tool on heart disease and depression - Created animation of CHD patient, kept authoritative provider video - Included links on how to find a counselor/therapy/cardiac rehabilitation in community (e.g., based on zip code/insurance) - Option not to address depression

Abbreviations: CHD Coronary Heart Disease; EHR electronic health record; eSDM electronic shared decision-making tool.

Provider level:

Key stakeholders expressed high acceptance for provider education and reminders and decision support. Cardiology stakeholders recommended markedly shortening educational materials to quickly emphasize the recommended action, how to do it, followed by information on depression and CHD. Transitions to remote work during the COVID-19 pandemic worsened time constraints and in-person meeting attendance rates. Therefore, the mode of delivery for education and behavioral feedback components included emails/newsletters sent out regularly by medical directors and brief educational videos that could automatically be delivered yearly. However, due to multiple competing priorities related to COVID-19 and a transition to a new EHR (Epic) across the institution, incorporating automated alerts/referrals or dashboards of CHD patients was not deemed feasible. Instead, an “iHeart” smartphrase (i.e., “dot phrases,” that allow commonly used chunks of text to easily be inserted into patient notes”) was considered another mode of delivery for reminding providers of referral options, including health behaviors such as nutrition and smoking cessation and treatment indications such as cardiac rehabilitation. Finally, the summary report was adapted to let providers know what to do upfront (including indications for cardiac rehabilitation, suicide risk). The report also included a cardiac health profile (e.g., compliance with tobacco, exercise, nutrition, medication adherence guidelines) to improve interest by cardiologists. Given the cultural change in engaging cardiologists in mental health care, summary reports were also delivered to PCPs and mental health providers at each site. In addition, given in-person constraints, the most feasible delivery of summary reports was via email and the Epic chat/inbox immediately prior to visits to align with workflow and assuage concerns that providers would not have time to review the results.

Patient level:

Initially, iPads in the waiting room were considered the most feasible, acceptable, equitable, and effective mode of delivery to ensure that all patients, regardless of digital access, were reached. Stakeholders initially reviewed an eSDM tool created for improving the sustainability of collaborative care models in primary care.²² However, given unique barriers and facilitators in CHD populations, stakeholders expressed that the tool would need to be re-designed. They unanimously felt that a patient video/testimonial might be less acceptable to mostly male CHD patients. Animators were enlisted to create an animation of a depressed CHD patient’s journey to depression treatment and healthy behaviors. As a contingency plan for providers who failed to refer CHD patients despite prompts and those CHD patients who elected not to address their mental health at their visits, links for finding mental health and cardiac rehabilitation resources were incorporated into the tool. Cardiology stakeholders further recommended eliciting cardiac behaviors (e.g., medication adherence, physical activity) and including a streamlined content hub on heart disease, mental health, lifestyle modification and treatment. It was incorporated at the end of the tool, which patients could review at leisure and repeatedly to facilitate long-term psychoeducation. After the COVID-19 pandemic, stakeholders recommended a multi-format, multi-modal tool, including a web-based application accessible via phone, tablet, or computer (in person or at home) as well as printed versions (e.g., mailer) of the tool to address digital literacy concerns. From a workflow perspective, the iHeart DepCare eSDM tool flexibly delivers screening within the tool or bypasses screening if screening is done adequately by the healthcare system (e.g., a medical assistant). Several psychiatry and cardiology stakeholders suggested a navigator to deliver the tool and help coordinate referrals. This was not deemed affordable or feasible. However, it was decided that the tool’s results would be sent to existing mental health navigators/providers at each clinical site to ensure follow-up for those patients who elected treatment (see system/provider level adaptation above). Relatedly, some CHD patient stakeholders had concerns about PCPs or cardiologists addressing depression, which might undermine their medical concerns. On the other hand, mental health stakeholders expressed that bypassing providers and automatically referring patients might overwhelm the limited mental health system. Delivery of tool results to mental health navigators/providers and alerting patients that their results would be delivered to their physicians assuaged both concerns. A user-centered design process for operationalizing and adapting the tool’s content along with usability testing results will be described in a separate manuscript.

Description of final implementation strategy

The final multi-component implementation strategy is presented in Figure 4 and Table 4. We determined that the most feasible multi-component strategy for promoting depression screening, referral, and treatment would include: (1) ongoing problem-solving meetings with physical and mental health providers to address contextual determinants of implementation, aligned with existing learning mental health collaborative meetings and delivered/led by staff to ensure sustainability;²² (2) cardiology/primary care provider education/motivation delivered by emailed videos/newsletters as well as summary reports of patient preferences and reminders/decision-referral support via the EHR/email; (3) a patient-level, multi-modal eSDM tool that includes depression screening, patient activation, treatment barriers assessment/mitigation, and a patient preference-driven treatment selection decision aid that delivers a cardiac mental health snapshot of depression treatment preferences and adherence to health behaviors to both clinical and mental health providers in real-time. The system and provider level strategies are imbedded within routine clinical care and delivered by existing administrators and clinician leaders in clinical sites to ensure affordability and sustainability (e.g., problem-solving meetings, screening videos, educational videos/newsletters, iHeart smartphrase). The eSDM tool along with the provider summary report will be facilitated by implementation team coordinators. We will assess the number of patients completing the tool alone or with assistance (including a family member), at home, or in the waiting room to determine feasibility, affordability, and sustainability.

Figure 4.

Final multi-level, multi-component iHeart DepCare implementation strategy and screenshots of tool prototype.

Key ERIC implementation strategies²³ that corresponded with our final set of behavior change techniques included model and simulate change, develop, and distribute effective educational materials, conduct ongoing training, audit and provide feedback, change physical structure and equipment, create a learning collaborative, and identify and prepare champions (Supplementary Table 4).

The implementation strategy here is currently being tested in a hybrid II clinical trial in 8 clusters of sites (with and without access to collaborative care for depression) to assess the impact on depressive symptoms (effectiveness) and referral/treatment uptake (implementation).³⁵ Final intervention materials will be made available at the end of the trial.

Discussion

Primary results

This paper provides a roadmap for using behavioral and implementation science to identify generalizable barriers and facilitators of implementation before designing a theory-informed, multi-level, and feasible implementation strategy for improving the adoption, implementation, and sustainability of proven cardiovascular medicine interventions in real-world clinical sites.³⁶

Based on the use case of depression screening and treatment in CHD patients, we determined that a multi-component implementation strategy would need to address several barriers at the system/provider level and at the patient level. The most acceptable, feasible, and equitable multi-component strategy (iHeart DepCare) that would target these barriers comprised several intervention functions, including education, persuasion, environmental restructuring for both levels, as well as enablement at the system/provider level. We also identified several ERIC strategies (i.e., learning collaborative, audit and feedback, educational materials) to promote comparisons of implementation strategies across studies in the field of implementation science. The final multi-component implementation strategy to promote behavior change at the system level would include problem-solving/learning collaborative meetings with clinical mental health staff. At the provider level, the strategy included educational and motivational videos and reminders/decisional-referral support via receipt of patient preferences in the EHR. To change patient level behavior, a multi-modal shared decision-making (eSDM) tool would provide screening functionality, psychoeducation, patient activation (around depression, heart disease and health behaviors), and patient preference-driven treatment selection support.

This study adds to prior research by synthesizing the barriers and facilitators of depression screening and treatment relevant to outpatient sites. There have been calls to consolidate and share knowledge on barriers and facilitators to implementation across multiple sites in order to prepare for scaling out evidence-based practices.³⁶ Davis and Beidas pointed out that “current methods to determine potential barriers and facilitators to implementation are often conducted in a single site and/or for a single evidence-based practice (EBP) per study… it is important to move toward cross-sector and/or cross-EBP contextual inquiry.” Our review identified determinants of depression screening and treatment implementation in CHD patients that are similar and unique across different sites (e.g., inpatient/outpatient, varied patient populations, and access to mental health care) to improve the generalizability of our strategy. While individual studies we reviewed focused on either provider or patient barriers to implementation, our synthesis suggests that a multi-level implementation strategy would be needed to address guideline implementation.

Developing effective implementation strategies requires identifying barriers to implementation at multiple levels and applying theoretical frameworks to qualitative findings. We highlight how the BCW framework can support a systematic, theory-informed process for targeting barriers to implementation. Though the BCW framework widely used in other areas, there have been few examples of studies in cardiovascular medicine and behavioral cardiology.^37–44 Taken together with our previous work²², this study suggests that there are unique barriers to mental health implementation in CHD populations and settings, which require unique strategies/content but that modes of delivery/intervention functions may be specific to contextual nuances of a health care setting. This study also addresses the lack of “comprehensive reporting of implementation strategy use and alignment of those strategies with implementation outcomes within clinical research [as] a missed opportunity to efficiently narrow research-to-practice gaps”.⁴⁵ We go on to expand application of the BCW framework from focusing on one primary behavior to considering inter-connected behaviors at the system, provider, and patient level to arrive at an implementation strategy that targets multiple behaviors.

Our study also answers several calls for theory-informed, multi-level implementation strategies to address health equity.^46,47 Research demonstrates that financial toxicity and other social determinants of health may limit the benefits of depression interventions in cardiac populations.^48,49 Here, we only selected those strategies with the potential for feasibly and equitably improving uptake of depression screening and treatment in diverse clinical sites (e.g., problem-solving meetings with mental health staff to maximize limited resources; multi-modality, low literacy educational tool that elicits cost-related barriers to treatment and adherence to treatment). Nonetheless, our study selected strategies from the healthcare system perspective. True impact on social determinants of health may require additional strategies that explicitly target financial barriers to treatment. We provide several suggestions for policy categories that may be considerations for payors, including aligning with Accountable Care Organizations’ depression screening quality metrics or leveraging policy-level technical assistance and fiscal policies to implement collaborative care.^50–52

Finally, our study fills the need for hybrid effectiveness-implementation studies in cardiovascular medicine. From an implementation perspective, there have been few attempts to implement depression screening and treatment in cardiac patients. Smolderen et al. described an implementation effort in a hospital site and found that many patients did not get screened, with only a modest impact on depression recognition rates.²⁶ One quality improvement initiative incorporated a screening checklist into a telephone-based nurse program for health plan post-MI patients, but results on treatment and depressive symptoms remain unknown.⁵³ Several mental health delivery models have also been tested in heart disease, including collaborative care, a team-based, stepped-care approach involving care management staff trained to provide evidence-based depression care in consultation with a psychiatrist.⁵⁴ Rollman et al. found that a telephone-based collaborative care program improved depressive symptoms and quality of life following coronary artery bypass graft surgery.⁵⁵ However, collaborative care faces multiple fiscal and resource/workflow-level barriers to implementation in real-world clinical sites.^56–58 Our trial will assess whether the proposed theory-informed strategy improves the adoption, sustainability, and fidelity of depression screening and treatment guidelines, using existing resources in sites with and without access to collaborative care programs while also leveraging problem-solving/learning collaborative meetings to improve the integration between psychiatry and medicine.³⁴

Limitations of the study

This study has several limitations. First, we conducted a narrative literature review as opposed to a systematic review. We determined that a comprehensive narrative review provides the most important and critical aspects of the current knowledge of the topic and would suffice to establish a theoretical framework and context for the research most effectively. While we attempted to be exhaustive, we may have missed relevant papers that described key barriers to implementation. We also focused on qualitative studies that are often influenced by social desirability bias and small sample sizes, but nonetheless allowed us to design a more generalizable and applicable implementation strategy. Second, we used the BCW framework to identify implementation strategies that promote behavior change. It is possible that other frameworks, such as the Consolidated Framework for Implementation Research (CFIR),⁵⁹ would have allowed us to identify implementation strategies that better target additional outer (e.g., policies) and inner (e.g., leadership support) contextual factors. Third, overlapping system and provider barriers and enablers described in the literature limited our ability to fully differentiate provider and system-level strategies. Fourth, while we highlight the implementation outcomes targeted by our implementation strategy components, few of our identified strategies address cost-related implementation outcomes. Future work will be needed to determine whether this multi-level strategy reduces costs associated with depression and heart disease in healthcare settings. Finally, a key step in implementation science is identifying contextual determinants (i.e., barriers and facilitators) of implementation in a given site and designing implementation strategies to address them.⁶⁰ Our strategy that targets generalizable determinants but was adapted for our local settings may not be applicable to all settings.

Conclusions

This paper demonstrates the applications of the BCW framework to inform multi-level behavior change, using depression screening and treatment in CHD patients as a use case. Our hybrid II effectiveness-implementation study will determine whether this multi-level implementation strategy, comprising a learning health collaborative, provider education/decisional support, patient-level activation, and shared decision making, will improve depressive symptoms, depression treatment initiation, and healthy behaviors.

What is Known

• Depression leads to poor health outcomes in coronary heart disease (CHD) patients.

• Despite guidelines recommending screening and treatment of depressed CHD patients, few patients receive optimal care.

What the Study Adds:

• Describes multi-level (patient and system/provider level) barriers and facilitators to depression screening and treatment in CHD populations based on a narrative review of the literature.

• Provides a generalizable, multi-level implementation strategy for improving the uptake of depression screening and treatment guidelines in settings caring for CHD patients.

• Provides a practical blueprint for applying implementation science to the field of cardiovascular medicine.

Non-standard Abbreviations

BCW

Behaviour Change Wheel

COM-B

Capability (e.g., knowledge), Opportunity (e.g., resources), and/or Motivation (e.g., self-efficacy) for a behavior

APEASE

Affordability, Practicability, Effectiveness and Cost-Effectiveness, Acceptability, Side-effects and Safety, Equity

ERIC

Expert Recommendations for Implementing Change

eSDM

Electronic shared decision-making

EBP

Evidence-based practice