Psychotherapy by Telephone Effective Addition to Depression Treatment

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Psychotherapy by Telephone Effective Addition to Depression Treatment

Newswise ‹ Integrating psychotherapy by telephone into a program for

treating depression can significantly improve outcomes, according to a study

in the August 25 issue of JAMA, the Journal of the American Medical

Association.

Both antidepressant medication and structured psychotherapy have been proven

effective, but less than one-third of people with depressive disorders

receive effective levels of either treatment, according to background

information in the article. Of those beginning psychotherapy, 25 percent

attend only one session and only half attend four or more sessions. Stigma

remains an important barrier to treatment seeking and treatment adherence.

Psychotherapy requires a significant commitment of time.

E. Simon, M.D., M.P.H., of the Center for Health Studies, Group

Health ative, Seattle, and colleagues conducted a randomized trial

between November 2000 and May 2002 evaluating two approaches to addressing

the barriers to effective depression treatment. The first program was an

updated version of a telephone outreach and care management program to

improve the quality of antidepressant pharmacotherapy. The second program

included telephone care management and added an 8-session structured

psychotherapy program delivered by telephone.

The study included 600 patients beginning antidepressant treatment for

depression in primary care clinics. The treatments included: usual primary

care; usual care plus a telephone care management program including three

outreach calls (each contact included a brief, structured assessment of

depressive symptoms, antidepressant medication use, and adverse effects),

feedback to the treating physician, and care coordination; and usual care

plus care management integrated with a structured 8-session

cognitive-behavioral psychotherapy program delivered by telephone, with each

session lasting 30-40 minutes. Sessions included discussing increasing

pleasant and rewarding activities, and identifying, challenging, and

distancing from negative thoughts. A participant workbook included

in-session exercises and written homework exercises for completion between

sessions.

The researchers found that compared with usual care, the telephone

psychotherapy intervention led to lower average scores on a scale measuring

depression. A higher proportion of patients reported that depression was

³much improved² (80 percent vs. 55 percent) and a higher proportion of

patients were ³very satisfied² with depression treatment (59 percent vs. 29

percent). The telephone care management program without the psychotherapy

component had smaller effects on patient-rated improvement (66 percent vs.

55 percent) and satisfaction (47 percent vs. 29 percent); effects on mean

depression scores were not statistically significant.

³Telephone programs may sacrifice the richness of traditional in-person

therapy, but they address several important barriers to dissemination of

effective depression treatments,² the authors write. ³Vigorous telephone

outreach allowed us to engage patients who might not be reached by

traditional in-person treatment. Telephone sessions eliminated travel and

waiting time and allowed more flexible scheduling. Greater privacy of

telephone contacts helped to circumvent stigma.²

³Efforts to improve management of depression in primary care must consider

resource limitations and pressures to control costs. While we estimate the

cost of providing telephone psychotherapy to be less than $50 per session,

these additional resources should be directed to those patients most likely

to benefit,² they add.

³Our findings demonstrate the feasibility, acceptability, and effectiveness

of a telephone-based program including medication monitoring, care

coordination, and structured, depression-specific psychotherapy. For primary

care patients beginning antidepressant treatment, brief structured

psychotherapy via telephone adds significantly to usual care pharmacotherapy

[drug treatment]. These findings suggest the need for a public health

approach to psychotherapy emphasizing persistent outreach and vigorous

interventions to improve access to and motivation for treatment,² the

authors conclude.

(JAMA. 2004; 292:935-942. Available post-embargo at http://JAMA.com)

Editor¹s Note: This work was supported by a grant from the National

Institute of Mental Health. Dr. Simon has received research funding from Eli

Lilly & Co. and Solvay Pharmaceuticals. An application for funding is

pending with Wyeth Pharmaceuticals. Dr. Simon has also received consulting

fees from Pfizer Pharmaceuticals for contributions to a patient education

program for people with bipolar disorder. Co-author Dr. Von Korff

has received research funding from GlaxoKline Pharmaceuticals and has

also received consulting fees from Astra Zeneca Pharmaceuticals for advice

regarding pain research.