Improving Depression Management in Primary Care (CDA 19-108)
Phase: NA
Conditions: Depression
Sponsor: VA Office of Research and Development

Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Version date: 07/19/2021
 
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Study Protocol & Statistical Analysis Plan 
 
Improving Depression Management in Primary Care 
NCT05050227 
July 19, 2021 
 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Page 2 
1. Introduction/Background 
VA’s Primary Care–Mental Health Integration (PC-MHI) is rooted in evidence-based collaborative care models, 
where care managers, mental health specialists, and primary care providers jointly treat depression in primary 
care. While PC-MHI enabled specialists to support medication treatment in primary care, timely and sufficient 
access to psychotherapy is unattainable1-3. Alternative therapy modalities are needed.  
Depression is disabling and affects one in five Veterans4. Psychotherapy is preferred by Veterans5, but fraught 
with multilevel barriers (e.g., staff availability, patient travel to clinic, limited clinic hours)6. Without enhancing 
existing PC-MHI models to enable better primary care patient access to effective psychotherapies, Veteran 
engagement in depression treatment is unlikely to improve. 
This intervention proposal aims to close the gap in psychotherapy access for VA primary care patients with 
depression by adapting PC-MHI collaborative care models to improve uptake of computerized cognitive 
behavioral therapy (cCBT). cCBT is accessible 24/7 via the internet and has effectively treated depression in 
more than 30 trials7-9. With modest specialist support, it is non-inferior to face-to-face psychotherapy10,11. PC-
MHI can facilitate Veteran uptake of cCBT, using an evidence-based collaborative care model to provide the 
follow- up care management and mental health specialist back-up that characterizes the most effective cCBT 
trials. 
2. Aims and Purpose 
This protocol is for “Pilot RCT”, a pilot randomized control trial to examine feasibility, acceptability, and potential 
effects of cCBT-enhanced collaborative care on Veterans’ depression outcomes in one primary care clinic, in 
preparation for a larger hybrid effectiveness-implementation trial. Overall, 74 eligible primary care patients with 
clinically significant depression will be 1:1 randomized to (1) cCBT-enhanced collaborative care; or (2) only VA 
usual care (UC), which typically includes medication prescription. Since a substantial proportion (25-60%) of 
patients with depression treated with just placebo have significant reductions in symptoms, the control group 
offers a more robustly designed pilot study to prepare for a larger RCT.  
Our primary hypothesis is that cCBT-enhanced collaborative care will be feasible and acceptable among 
Veterans in primary care. We also hypothesize that patients receiving cCBT-enhanced collaborative care may 
report moderate improvements in depression symptoms, compared to patients receiving UC at 3-months 
follow-up. Finally, we hypothesize that the cCBT-enhanced group will have improvements in behavioral/patient 
activation, health-related quality of life, and other mental health symptoms, compared to UC patients. 
3. Activities Overview 
Study participants will be randomized to either Usual Care (UC), typically medication, under their own PCP or the 
Intervention. Those in the intervention arm will receive cCBT-enhanced collaborative care supported by a 
depression care manager. The depression care manager (a licensed social worker) will facilitate access to cCBT, 
promote and monitor cCBT use, reinforce CBT concepts (during outside CBT session “homework”), and monitor 
mental health symptoms for each participant. Participants will be contacted weekly via 15-30-minute phone 
calls or by other means (e.g., email, Vets Prevail platform).  Additionally, a Primary Care and a Psychiatry 
Consultant will meet weekly with the depression care manager in order to oversee study patient progress and 
the cCBT-enhanced collaborative care model broadly.  
Computer-based CBT (cCBT) will be provided via the VA-sponsered Vet’s PrevailSM program. This program is free 
for all Veterans, provides self-paced CBT lessons tailored to patients based on sociodemographics, and engage 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Page 3 
users with modest financial incentives (e.g., gift cards). It also features a community message board, a peer 
support specialist chat support, and safety monitoring that includes warm-handoffs to the VA Crisis Chat Line. 
4. Study Design 
This is a 2-year pilot randomized control trial to assess the feasibility, acceptability, and potential effects of a 
cCBT-enhanced collaborative care model on depression symptoms and related outcomes. 
Eligible and consenting patient subjects will be randomly assigned to one of two treatment conditions: 1) cCBT-
enhanced collaborative care (n=37), or 2) usual care (n=37). Randomization to condition will be stratified by 
gender, to account for differences in care delivery structure and for in treatment outcomes.  
4.1. Data collection methods 
A study team member will perform baseline (0-month) assessments immediately following informed consent 
during a 45-60-minute telephone (or in-person interview should it be necessary). A research assistant (RA) will 
perform the post-intervention (3-month) assessments during another 45-60-minute telephone interview. Post-
intervention assessments will only differ between intervention and control arms by inclusion of feasibility and 
acceptability questions (e.g., CSQ-8) for intervention participants only. As in prior studies, the GLA Veteran 
Engagement Team members provided feedback on assessment content and timing. See Table 1, for a list of 
measures. 
 
Measure 
Pre- 
(# of items) 
Post- 
(# of items) 
PROMIS Global Health 
10 
10 
Patient Activation Measure (PAM-13) 
13 
13 
Behavioral Activation for Depression Scale (BADS-SF) 
9 
9 
Patient Health Questionnaire (PHQ-9) 
9 
9 
General Anxiety Disorder (GAD-7) 
7 
7 
PTSD Checklist for DSM-5 (PCL-5) 
20 
20 
Alcohol Use Disorders Identification Test (AUDIT-C) 
3 
 
Screening Test for Drug Use  
2 
 
Medication use 
3/CR 
3/CR 
Health Services Use 
11 
11 
Chronic conditions 
CR 
 
Demographics (age, gender, race/ethnicity, marital status, education level, 
employment status, homelessness) 
5 (+2 CR) 
 
MEASURES FOR INTERVENTION ARM ONLY 
Client Satisfaction Questionnaire (CSQ-8) 
 
8 
System Usability Scales (SUS) 
 
10 
Open-ended questions (liked, disliked, suggestions for improvement) 
 
3 
 
92 
103 
Table 1: Data Collection Measures. CR=chart review 
 
 
 
4.2. Sample description, development and rationale 
74 (37 male, 37 female) Veterans will be recruited from the Greater Los Angeles Healthcare System, using a mix 
of purposive and convenience sampling. Purposive sampling will entail using electronic medical records (e.g., 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
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services utilization, depression diagnostic codes and/or screening data from CDW or other database) for 
targeted mailing of recruitment letter and flyer. Convenience sampling will entail posting flyers on physical 
buildings and social media, accepting referrals from providers.  
Sample Sizes and Power Analyses: The trial will have the power to detect an effect size (ES) of 0.78 or greater ITT 
on the PHQ-9 of cCBT-enhanced collaborative care versus UC patients at 3-month follow-up. Data are based on 
Richards et al’s 2012 study,10 which reported a d=0.78 ES for therapist-guided cCBT trials for improving 
depression outcomes. This is consistent with literature showing that therapist support yields greater effects for 
cCBT.10 Assuming an 80% 3-month assessment completion rate (consistent with prior relevant studies)12-14 and 
2-tailed type I error of 0.05, if we then enroll 37 subjects to the intervention arm and 37 to the control arm (74 
total) we will have 80% power to detect at least a 0.78 ES improvement of cCBT-enhanced collaborative care 
over usual care on the PHQ-9 (primary hypothesis). The pilot is not powered to detect changes in HRQoL or 
differences by gender.  
4.3. Participant interactions and interventions 
Participants in cCBT-enhanced collaborative care arm (i.e. intervention arm) will be enrolled in VA-sponsored 
computerized cognitive behavioral therapy (cCBT) program, Vets PrevailSM. This cCBT program delivers 5 
sessions of CBT online via desktop or mobile app, features a community message board, and provides peer 
support specialist chat support and safety monitoring (e.g., warm handoffs to the Crisis Chat Line). A licensed 
social worker with a master’s degree and knowledge/experience delivering CBT will serve as a care manager. 
The study care manager will facilitate access to cCBT, promote and monitor cCBT use, reinforce CBT concepts 
(during outside CBT session “homework”), and monitor mental health symptoms for each participant. She will 
contact them weekly via 15-30 minute phone calls or other means (e.g., email, Vets Prevail platform) for 3 hours 
total. The goal is to encourage patients to complete the online CBT modules over a total of 3 months. As such, 
the caseload is approximately 6 Veterans per 8 weeks, totaling 37 intervention arm participants over 12 months. 
A psychiatrist consultant and Primary Care consultant will meet weekly with the study care manager to oversee 
study patient progress and the cCBT-enhanced collaborative care model broadly. Brief electronic health record 
(EHR) template notes will be completed at study enrollment and conclusion and additional notes as needed, if 
patient safety monitoring protocols are activated 
Patients in the control condition will receive care that is consistent with recommended VA practice – usually 
PCP-prescribed antidepressant medications and/or referral to see a mental health specialist (who usually offers 
a brief assessment and a few short visits). The VA also has a wide suite of veteran-centric digital mental health 
tools for depression, posttraumatic stress, insomnia, etc., which are publicly available and free. 
Participants will be assessed in both conditions at baseline and 3 months (post-intervention) via 45-60 minute 
telephone interviews. The baseline assessment will measure depression and other mental health symptoms; 
health-related quality of life; patient activation; demographics; physical and mental health comorbidities; 
substance use history; and treatment utilization. The 3-month assessment will re-measure depression and other 
mental health symptomatology; health-related quality of life; patient activation, plus assess intervention group 
participants’ satisfaction with treatment; cCBT program usage; and interactions with care management. 
Intervention entails the cCBT-enhanced collaborative care, using VA-sponsored Vets Prevail. 
Compensation: Participants will be compensated with $30 VCS vouchers for completing the baseline assessment 
and a $45 VCS voucher for completing the 3-month assessment ($75 total). Vouchers will be distributed at the 
time assessments are completed. 
5. Recruitment and Consent 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
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5.1. Recruitment Methods 
Veterans will be recruited from VA Greater Los Angeles (GLA) Healthcare System primary care clinics (e.g., 
Primary & Ambulatory Care Clinic, Women’s health Clinic), except for individuals empaneled to the study PI to 
avoid the possibility of coercion. Patients with clinically significant depression (as detected on mandated annual 
screening or other means) will be referred by their primary care or mental health teams. Additionally, local case 
finding activities will be conducted for targeted mailing of recruitment letters and flyers.  
Direct Referrals: The study team will advertise the study through clinical staff meetings and emails to providers. 
The study team will be available online (via MS Teams, email, telephone).  
Mailers: The study team will identify Veterans based on screening data (e.g., Patient Health Questionnaire – 2), 
diagnostic codes, encounter data, antidepressant medications, and suicide flags from the Corporate Data 
Warehouse and other VA databases.  
A recruitment letter and study flyer will be mailed (via USPS) to the potential participant from their provider, 
clinic, or program representative (e.g., primary care providers), only if the provider agrees to the study team 
reaching out to the Veteran on their behalf. Mailings will describe the purpose of the study and request that the 
potential participant initiate contact with the study team (via phone or email) to indicate his/her agreement to 
participate. If no response is made within a 2-week period, the potential participant may then be contacted by 
phone. We will not conduct any “cold calls”, that is use prior knowledge of private information to initiate contact 
with the potential participant, who would otherwise not know the study team. 
Flyers and Social Media: The research team will advertise the study directly to Veterans via flyers developed for 
both male and female Veterans. The flyers contain the study phone number and email contact information and 
provide the Project Coordinator’s contact information to answer any questions. As in prior studies, the GLA 
Veteran Engagement Team was consulted regarding design and content of recruitment flyers. Local primary care 
and mental health clinic teams will be consulted regarding flyer placement and distribution. In addition to 
physical posting of recruitment flyers, the study team will contact VA media for assistance with electronic 
distribution of the flyer (e.g., display on campus TVs or on social media). 
5.2. Informed Consent Procedures 
All study procedures for this component will be conducted via telephone and the internet. For this reason, we 
will request a HIPAA waiver and a Waiver of Documentation of Informed Consent from the IRB. 
We will obtain verbal consent and study team members will be trained to recognize signs of cognitive and 
hearing impairment. Veterans who self-report that they are unable to hear the project coordinator will be asked 
to paraphrase the first sentence of the study procedures. Veterans who cannot accomplish this task will be 
excluded from participation. Veterans who do not initially self-identify as hearing impaired will also be excluded 
from participation if they indicate not being able to hear or understand the consent items after they are 
repeated 3 times. 
The study PI will ensure that all study team members are up to date with VA trainings on human subjects 
protection, government ethics, privacy and HIPPA, and information security, as well as project-specific training. 
 
5.3. Inclusion/Exclusion Criteria 
Inclusion: 
• 
Have access to computer (mobile or desktop), internet, telephone, and email 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Page 6 
• 
Able to read English text on a computer screen 
• 
Score 10 or higher on the PHQ-9 
Exclusion: 
• 
Have moderate-high suicide risk (e.g., suicide flag) or active suicidality 
• 
Have other serious mental illness (e.g. bipolar disorder, psychosis) or medical disorder that would 
prevent/interfere with participation (e.g. dementia/cognitive impairment, terminal illness).  
6. Data Sources and variables 
Study team members will perform baseline (0-month) and 3-month (post-intervention) assessments. 
Deidentified data (containing study participant ID) will be entered into VA REDCap or a comparable database 
which supports trial data and will then be exported securely for analyses after study conclusion. See Table 3 for 
a list of primary and secondary outcomes and covariates.  
 
Constructs 
Measures 
Data Source 
Primary Outcomes 
Acceptability 
 
Feasibility 
Recruitment 
 
Intervention 
Client Satisfaction Questionnaire (CSQ-8),  
Open-ended questions (likes, disliked, suggestions for improvement) 
Number, proportion, and representativeness of participants 
Reasons for declined participation and/or study termination 
Number, proportion, and representativeness of referring providers 
Number, duration, and type of care manager contacts 
cCBT usage activity (registration, enrollment, completion, messaging) 
Patient 
Patient 
Study Data 
Study Data 
Study Data 
Vets Prevail 
Vets Prevail 
Depression 
Patient Health Questionnaire (PHQ-9) 
Patient 
Secondary 
Quality of life 
Activation 
 
Anxiety 
PTSD 
Promis-10 Global Health 
Behavioral Activation for Depression Scale (BADS-SF) 
Patient Activation Measure (PAM-13) 
Generalized Anxiety Disorder (GAD-7) 
PTSD Checklist for DSM-5 (PCL-5) 
Patient 
Patient  
Patient 
Patient 
Patient 
Covariates 
Demographics 
 
Other patient 
information 
Alcohol use 
Substance use 
 
Antidepressant use 
Health services use 
Age, gender, race/ethnicity, marital status, education level, 
employment status, and housing status 
Distance from home to clinic, combat status, service connection, 
medical & psychiatric diagnosis, empaneled PCP 
Alcohol Use Disorders Identification Test (AUDIT-C) 
Single Item Drug Screen 
Single Item Cannabis Use  
Per medication list (6 months before & after intervention) 
Mental health, PC0MHI, primary care, etc. (6 months before) 
Patient 
 
Chart 
Review 
Patient 
Patient 
Patient 
Chart review 
Patient 
Legend: Implementation outcomes shaded in gray 
Table 3: Data Sources. 
 
7. Data Analysis 
An electronic database for data entry and management (using VA REDCap or other comparable software) will be 
built. We will perform all data analyses using STATA15 other available statistical package. A statistician will be 
available for consultation in statistical design and analyses but will not have access to identifiable patient data. 
The full analysis set will be based on an intention-to-treat (ITT) analysis, which will comprise all participants who 
have been randomized to either study arm, regardless of length of follow-up or actual intervention received.  As 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Page 7 
a preventive measure, every attempt will be made to document all reasons for missing data and will compare 
the rates of lost-to-follow-up between study arms. In addition, baseline characteristics will be compared 
between participants who do and do not withdraw from the study, to assess the impact of missing information 
and attrition.  
Demographic and baseline characteristics (e.g., demographics, combat status, alcohol and substance use 
disorders, medication use, health services use) will be presented as mean and standard deviations for 
continuous variables and sample proportions for categorical variables. All descriptive statistics will be 
accompanied by 95% confidence intervals. Baseline comparisons between study arms (for each hypothesis) will 
be performed using t-tests for continuous variables, chi-squared tests for categorical variables, or their 
nonparametric counterparts. Diagnostics (i.e., conditional studentized residuals, plots of outcomes over time) 
will be performed on each linear mixed model to assess whether necessary assumptions were met. 
To assess feasibility, the number of participants approached each month, the proportion who enroll, the rate 
and timing of dropouts, the proportion of referring providers, and the number of study care manager contacts 
will be calculated. Additionally, Vets Prevail program usage data, including the proportion of participants in the 
intervention arm who become registered users, enroll in the cCBT program, and complete the entire cCBT 
program will be calculated; Vets Prevail data will be further aggregated to understand average/median duration 
of and number of completed cCBT sessions, community message board posts, and peer chats.  
To quantify acceptability, summary statistics (e.g., median/mean) for CSQ-I items scores will be computed. 
Under an health anthropologist’s guidance, responses to the open-ended survey questions will be categorized as 
positive, neutral, negative, or ambivalent. Responses will be independently coded by multiple people, resolving 
disagreements through discussion and examining positive and negative factors.15 
To assess feasibility, acceptability, and other depression related outcome measures, generalized linear mixed 
model (GLMM) will be used, which provides a unified framework for the analysis of outcome trajectories over 
time by allowing for the modeling of repeated measures for each participant. GLMM is robust to imbalanced 
designs and provides unbiased estimates even when data are missing at random. GLMM will be fit as a function 
of study arm, time, time-by-study arm, and gender. In addition, the intercept will be allowed to vary randomly to 
account for subject-level variability of the outcome at baseline. [standard errors will be adjusted to account for 
provider/clinic clustering.] Analyses will first be conducted on complete data only and will estimate the adjusted 
mean difference in 3-month improvement on PHQ-9 (depression symptoms), GAD-7 & PCL-5 (other mental 
health symptoms), PROMIS (HRQoL), and BADS-SF/PAM-13 (behavioral/patient activation) between cCBT-
enhanced collaborative care and control arms. As an exploratory measure, we will conduct additional analyses 
on study outcomes using predefined numbers of completed cCBT sessions (e.g., >2 sessions, all 5 sessions). 
Sample Sizes and Power Analyses: The primary purpose of this pilot is to assess feasibility of trial methods, 
including recruitment, intervention, and follow-up. Nevertheless, given the sample sizes we plan to enroll, the 
trial will have the power to detect an effect size (ES) of 0.78 or greater ITT on the PHQ-9 of cCBT-enhanced 
collaborative care versus UC patients at 3-month follow-up. Data are based on Richards et al’s 2014 study,10 
which reported a d=0.78 ES for therapist-guided cCBT trials for improving depression outcomes, which is slightly 
higher than the reported ES (d=.56) for the Vets Prevail RCT. This is consistent with literature showing that 
therapist support yields greater effects for cCBT.10 Assuming an 80% 3-month assessment completion rate 
(consistent with prior relevant studies)12-14and 2-tailed type I error of 0.05, if 37 subjects are enrolled to the 
intervention arm and 37 to the control arm (74 total) 80% power to detect at least a 0.78 ES improvement of 
cCBT-enhanced collaborative care over usual care on the PHQ-9 (primary hypothesis) will be achieved. The pilot 

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
Page 8 
is not powered to detect changes in HRQoL. We lack pre-existing data to estimate effects on behavioral/patient 
activation. It is underpowered to detect differences by gender. Other analyses, e.g., access, is exploratory. 
8. Timeline 
 
 
 
Project Timeline
Y0
FY 20
Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3
PC-MHI provider interviews
VA stakeholder advisors
PCP interviews
Veteran focus groups
IRB determination
Participant recruitment
Pilot intervention
Data collection
Analyses
Paper 3
Research brief
Completed
In Progress
Planned
Pilot RCT
Year 1
FY 21
Pre-Pilot
Year 2
Year 3
FY 22
FY 23

Project Title: Improving Depression Management in Primary Care (CDA-19-108) 
PI: Lucinda Leung 
 
 
Protocol (1616118-5 Leung 07-19-21)_clinicaltrials.gov_LL_ceb 
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9. Relevant publications 
1. 
Farmer MM, Rubenstein LV, Sherbourne CD, et al. Depression Quality of Care: Measuring 
Quality over Time Using VA Electronic Medical Record Data. J Gen Intern Med. Apr 2016;31 Suppl 
1:36-45. doi:10.1007/s11606-015-3563-4 
2. 
Funderburk JS, Sugarman DE, Labbe AK, Rodrigues A, Maisto SA, Nelson B. Behavioral 
health interventions being implemented in a VA primary care system. J Clin Psychol Med Settings. 
Mar 2011;18(1):22-9. doi:10.1007/s10880-011-9230-y 
3. 
Leung LB, Escarce JJ, Yoon J, et al. High Quality of Care Persists With Shifting Depression 
Services From VA Specialty to Integrated Primary Care. Med Care. Aug 2019;57(8):654-658. 
doi:10.1097/MLR.0000000000001141 
4. 
Yano EM, Chaney EF, Campbell DG, et al. Yield of practice-based depression screening in VA 
primary care settings. Journal of general internal medicine. 2012;27(3):331-338.  
5. 
Lin P, Campbell DG, Chaney EF, et al. The influence of patient preference on depression 
treatment in primary care. Ann Behav Med. Oct 2005;30(2):164-73. doi:10.1207/s15324796abm3002_9 
6. 
Mohr DC, Hart SL, Howard I, et al. Barriers to psychotherapy among depressed and 
nondepressed primary care patients. Ann Behav Med. Dec 2006;32(3):254-8. 
doi:10.1207/s15324796abm3203_12 
7. 
Andrews G, Basu A, Cuijpers P, et al. Computer therapy for the anxiety and depression 
disorders is effective, acceptable and practical health care: An updated meta-analysis. J Anxiety 
Disord. Apr 2018;55:70-78. doi:10.1016/j.janxdis.2018.01.001 
8. 
Dedert E, McDuffie JR, Swinkels C, et al. Computerized Cognitive Behavioral Therapy for 
Adults with Depressive or Anxiety Disorders. 2013. VA Evidence-based Synthesis Program Reports. 
9. 
Webb CA, Rosso IM, Rauch SL. Internet-Based Cognitive-Behavioral Therapy for Depression: 
Current Progress and Future Directions. Harv Rev Psychiatry. May/Jun 2017;25(3):114-122. 
doi:10.1097/HRP.0000000000000139 
10. 
Richards D, Richardson T. Computer-based psychological treatments for depression: a 
systematic review and meta-analysis. Clin Psychol Rev. Jun 2012;32(4):329-42. 
doi:10.1016/j.cpr.2012.02.004 
11. 
Thase ME, Wright JH, Eells TD, et al. Improving the Efficiency of Psychotherapy for 
Depression: Computer-Assisted Versus Standard CBT. Am J Psychiatry. Mar 1 2018;175(3):242-250. 
doi:10.1176/appi.ajp.2017.17010089 
12. 
Hobfoll SE, Blais RK, Stevens NR, Walt L, Gengler R. Vets prevail online intervention reduces 
PTSD and depression in veterans with mild-to-moderate symptoms. J Consult Clin Psychol. Jan 
2016;84(1):31-42. doi:10.1037/ccp0000041 
13. 
Nelson CB, Abraham KM, Walters H, Pfeiffer PN, Valenstein M. Integration of peer support 
and computer-based CBT for veterans with depression. Comput Hum Behav. 2014;31:57-64. 
doi:10.1016/j.chb.2013.10.012 
14. 
Rollman BL, Herbeck Belnap B, Abebe KZ, et al. Effectiveness of Online Collaborative Care 
for Treating Mood and Anxiety Disorders in Primary Care: A Randomized Clinical Trial. JAMA 
Psychiatry. Jan 1 2018;75(1):56-64. doi:10.1001/jamapsychiatry.2017.3379 
15. 
Marcinowicz L, Chlabicz S, Grebowski R. Open-ended questions in surveys of patients' 
satisfaction with family doctors. J Health Serv Res Policy. Apr 2007;12(2):86-9. 
doi:10.1258/135581907780279639