SOURCE: JAMA and Archives Journals Website
Psychotherapy by Telephone an Effective Addition to Treatment for
Depression
BETHESDA, MD -- August 25, 2004 -- 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.
Gregory E. Simon, M.D., M.P.H., of the Center for
Health Studies, Group Health Cooperative, 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 "much improved" (80 percent vs. 55 percent) and a higher
proportion of patients were "very satisfied" 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.
"Telephone programs may sacrifice the richness of
traditional in-person therapy, but they address several important barriers to
dissemination of effective depression treatments," the authors write. "Vigorous
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."
"Efforts 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," they add.
"Our 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," the authors
conclude. (JAMA. 2004; 292:935-942. Available post-embargo at JAMA.com)
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. Michael Von Korff has received
research funding from GlaxoSmithKline Pharmaceuticals and has also received
consulting fees from Astra Zeneca Pharmaceuticals for advice regarding pain
research.
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