By Kristina Fiore, Staff Writer, MedPage Today
Published: June 05, 2012
- Although psychotherapy effectively treats depression and is preferred to antidepressants by many primary care patients, only a small percentage of patients follow through and the attrition rate is high. This randomized study examined the efficacy of telephone-administered cognitive behavioral therapy of patients with major depressive disorder.
- Note that the study found that providing cognitive behavioral therapy over the telephone compared with face-to-face resulted in lower attrition and close to equivalent improvement in depression, but at the cost of some increased risk of poorer maintenance of gains after treatment cessation.
Receiving cognitive behavioral therapy (CBT) over the phone is just as effective in primary care patients as when counseling is done face-to-face, and phone CBT may keep patients in treatment longer, researchers found.
Patients had significant improvement in depression scores with both means of treatment (P<0.001), but significantly fewer stopped telephone-based therapy (P=0.02), David Mohr, PhD, of Northwestern University in Chicago, and colleagues reported in the June 6 issue of the Journal of the American Medical Association.
But they noted that patients were more likely to maintain improvements in depression 6 months after sessions stopped if they received face-to-face treatment.
“The increased adherence associated with telephone CBT may come at the cost of some increased risk of poorer outcomes after treatment cessation,” they wrote.
Roughly 25% of all primary care visits involve patients with clinically significant levels of depression, the authors pointed out.
Studies have shown that while CBT is an effective treatment for depression, only a small percentage of patients follow through because of barriers to access such as time constraints, transportation problems, and cost.
Yet some work has shown that giving CBT over the phone may help increase compliance.
So Mohr and colleagues conducted a randomized trial of 325 primary care patients in the Chicago area who had major depressive disorder from November 2007 to December 2010.
All patients had 18 sessions of CBT, either over the phone or face-to-face. All sessions were 45 minutes long, with two sessions a week for the first 2 weeks, followed by 12 weekly sessions, with two final booster sessions over 4 weeks.
The primary outcome was attrition at week 18, and secondary outcomes included interviewer- and self-reported depression scores.
The researchers found that significantly fewer patients discontinued telephone-based therapy compared with in-person therapy before week 18 (20.9% versus 32.7%, P=0.02).
Differences in attrition were apparent as early as week 5, with significantly fewer drop-outs in the telephone group (4.3% versus 13%, P=0.006), suggesting the effects of phone-base CBT on adherence “appear to occur during the initial engagement period,” likely because barriers to access most often occur early in treatment, the researchers wrote.
Both treatments significantly improved depression (P<0.001) and there were no between-group differences at 18 weeks in terms of physician- or self-reported depression scores.
Also, calculated effect sizes revealed that telephone-based therapy wasn’t inferior to face-to-face treatment.
Participants remained significantly less depressed 6 months after the intervention compared with baseline (P<0.001), but those who had face-to-face treatment were significantly less depressed than those in the phone intervention group in terms of both physician- and self-reported scores (P<0.001 and P=0.004, respectively).
Meeting face-to-face may be therapeutic in a way that promotes the maintenance of improvements in some patients, the researcher said, or the physical presence of the therapist may have some beneficial effects that last.
“If the finding that face-to-face treatment produces better maintenance of gains after treatment cessation is not an artifact, it suggests that longer-term follow-up is critical in research examining the effects of tele-mental health intervention and telemedicine more broadly,” they wrote.
The study was limited in its generalizability because the sample was fairly well educated, the researchers cautioned, and because it wasn’t possible to mask patients to the treatment arm.
Still, they concluded that telephone CBT “can overcome barriers to adhering to face-to-face treatment.”
The study was supported by a grant from the National Institute of Mental Health.
The researchers reported no conflicts of interest.
Primary source: Journal of the American Medical Association
Mohr DC, et al “Effect of telephone-administered versus face-to-face cognitive behavioral therapy on adherence to therapy and depression outcomes among primary care patients” JAMA 2012; 307: 2278-2285.