The Phone Phenomenon: Teletheraphy’s Effectiveness In Treating Depression

Posted on June 23, 2012 by

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“I just sit in my comfy chair and chat–and, yup, I feel loads better!” (image from freedigitalphotos.net)

I quite enjoy meeting patients in my office. I’ve decorated it just to my taste, including a high-backed, red-cushioned chair for my own person–but, more importantly, there’s something so real about meeting someone face-to-face, and traversing together their emotional terrain. Eyebrow language, foot-shaking, turning the nearby lamp on or off–all communications from the inner self.

However, I’d never undersell sessions on the phone. Any appointment for which I don’t have to put on make-up, shoes, and jewels  has a whole lot going for it. From the cleint’s point of view–the mroe significant one– I was able to help people via phone who couldn’t have worked with me otherwise, whether due to distance, or disability, or moving away once we had already begun in person. So I’ve done what they now call teletherapy since the late 80s.

Apparently I was on ‘the cutting edge’ of something once. Who knew?

As David Mohr,  professor of preventive medicine at Northwestern University Feinberg School of Medicine in Chicago notes in his 2008 paper, “The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis,”

In 1996, a report developed by an American Psychological Association task force found that empirical evidence concerning telephone-administered psychotherapy was scant to non-existent.

We’ve come a long way, baby. Working with a client via bluetooth no longer requires me to sit for an hour tethered to a pre-portable-phone–and it is no longer unheard of in the research community.

By the late 90s insurance companies, the VA, and HMOs were pushing telephone therapy as a cheap and effective treatment for depression.*

*[Note: Almost all the studies that have been done on tele-therapy have been done on depression.]

In fact, by a 2000 study, VandenBoos & Williams found that over two-thirds of psychologists used telephone-administered psychotherapy to some degree in their practices.

The landscape had changed, so much so, that by 2008, David Mohr felt ready to undertake one of the activities I enjoy most when reading research–the meta-analysis. [Doesn't it sound great, I ask you? No lab, no random controlled study, no pills, no patients, for crying out loud--just other people's work to critique as you will. What a research dream.]

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Now let’s step back for a few moments, and recall the purpose of tele-therapy in the first place.

Simon et al (2004) noted that telephone treatments may

 sacrifice the richness of traditional in-person therapy, but they address several important barriers to dissemination of effective depression treatments.

The advantages seem to far outweight the disadvantages:

  • The telephone is clearly superior when viewed through the prism of time expenditure. It does away with travel and waiting time, and allows for more flexible scheduling.
  • For the severely depressed patient, the burden of getting up and moving and dressed to the session is eliminated; all that is required is a phone call.
  • I’ve worked with patients for whom getting to the office was a hardship. Although I try to do home visits to my cancer patients when they are really homebound, at times scheduling doesn’t permit, and a phone session allows them to get the therapy they emotionally need, but their bodies won’t allow.
  • In rural areas or small towns, there may not be easy access by car to therapists, all the more so if you want someone with expertise in a given area.

In short, as  Mohr notes,

 many people want therapy as part of their depression treatment, but “one of the things we’ve found over the years is that it’s very difficult for people with depression to access psychotherapy.” In addition to the expense, if health insurance doesn’t cover it completely, therapy requires a time commitment — sometimes an hour or more a week for months — that is a challenge for people to meet. [see Reuters Health]

Fundamentally ease of access makes a tremendous difference, since the number of patients who don’t follow through with therapy is amazing.

When faced with the truth that they must do something to treat their depression, depressed patients overwhelmingly prefer the idea of psychotherapy to medication.  Be that as it may, Mohr found that

when referrals for psychotherapy are made, only 20% ever follow up, and of these, half drop out of treatment. [emphasis mine]

[On a side note, for those who travel the medicine route, the prospects are somewhat brighter relatively speaking--but still quite grim. Of those who begin taking antidepressants, a full 40% discontinue within the first month--and around 25% receive even minimal levels of follow-up (Simon G et al, 2001).]

That is a serious problem–both for the ill, and for the treatment community.

Thus it would seem that the first battle in the war to healing the depressed patient would be simply getting them to stick with their therapy.

It is here, in tackling of attrition, that all roads point to the telephone for psychotherapy.

In Mohr’s later, 2012 work, he studied 235 patients with major depressive disorder and compared face-to-face Cognitive Behavioral Therapy (CBT) vs telephone administered CBT for the treatment of depression in primary care

Significantly fewer discontinued telephone CBT (T-CBT) when compared with face to face (20.9% vs 32.7%). And, looking at early attrition, where rates are often particularly high, attrition before week 5 was significantly lower in T-CBT at 4.3% than in face-to-face CBT, with the much larger 13%. By the end of Mohr’s study, with patients receiving 18 CBT sessions, still significantly fewer patients receiving therapy by phone dropped out than those who got their treatment in the therapist’s office.

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Let’s return for a moment to the concept of efficacy, and to Mohr’s meta-analysis.  Mohr et al analyzed 12 studies–8 therapists utilized CBT, but the other 4 made use of a varying number of techniques, including, for example, interpersonal psychology.

The gold standard among research is the randomized controlled trial, and Mohr and company found one (of several) in Simon et al’s 2004 study “Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment,” which it pays to take a look at.

Simon et al studied 600 patients receiving antidepressant treatment.

They initially assessed depression utilizing the Hopkins Symptom Checklist  Depression Scale  ( SCL). Later depressive symptoms were re-assessed, in blinded interviews, via telephone interviews at 6 weeks, 3 months, and 6 months.

Researchers randomly divided subjects up into three groups; those receiving:

  • usual primary care (primary care physician oversaw medication management and therapy);
  • usual care plus a telephone care management program (included at least 3 outreach calls, feedback to the treating physician, and care coordination); and
  • usual care plus telephone care management plus a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone. [The telephone psychotherapy program was an addition to, rather than a substitute for, telephone care management. As such I wasn't totally shocked and awed when this group with the most attention and services did the best--I hope I'm not ruining the ending for people.]

In short, over the time of the study, the groups performed exactly how I–and I imagine most people with some little bit of knowledge here–predicted they would.

As the graph depicting the results demonstrates

improvement in SCL depression score was greatest in the telephone psychotherapy group, intermediate in the telephone care management group, and least in the usual care group.

And. . .

patients assigned to telephone psychotherapy were significantly more likely to experience a 50% improvement in SCL depression score than were usual care patients.

.

Course of Hopkins Symptom Checklist Depression Scale (SCL) Depression Scores Over Time According to Treatment Assignment from Simon et al, 2004

By SCL scores, the telephone care management group had  an intermediate rate of response by this measure, not significantly different from those receiving usual care.  However,

Both telephone psychotherapy and telephone care management participants were significantly more likely than usual care participants to describe themselves as “much improved” or “very much improved.”

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Now let’s return to Dr. Mohr’s current study, the one comparing head-on face-to-face cognitive behavioral therapy (CBT) with telephone-administered cognitive behavioral therapy  (T-CBT).

The study’s main focus was on completion vs non-completion post-treatment, but secondarily it assessed depressive symptoms, too.

In terms of staying with the treatment, T-CBT had it all over face-to-face treatment. 20.2% of the T-CBT patients discontinued treatment by week 18, as opposed to the significantly larger 32.7% who terminated their face-to-face CBT. Additionally, T-CBT patients attended significantly more sessions than did their counterparts who saw the therapists in person.

Then the crucial question became: Yes, the patients stick with T-CBT much better than face-to-face therapy–but is its quality as good as the in-person treatments?

Well, both sets of subjects improved significantly post-treatment.

The percentages  of improvement were so similar between the 2 groups as to be almost insignificant, as 23% of T-CBT patients still met the criteria for major depressive disorder post treatment compared with 25% in the face-to-face CBT.

Those numbers are so close that the authors said,

After 18 weeks of treatment, the depression declines were equivalent in the two groups. 

Interestingly at a 6-month follow-up, the depressive rates shifted–it became 29% for T-CBT and the lower 26% for face-to-face treatment.

In terms of that slight shift, though, to greater effectiveness of face-to-face CBT at the 6-mont point, there are a couple of theories. The obvious one, of course, is that something inherent in the interpersonal interactions between patient and therapist make that treatment longer-lasting. But that isn’t necessarily the most compelling reason for the statistical change.

Another very real possibility is that patients who were not doing well and  whose depression was not lifting dropped out of the face-to-face study earlier, so those that were left were a hardier, more resilient bunch, and their intensive work in making it to session after session kept paying off, even 6 months later.

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So here’s the sum of it: teletherapy has a lower attrition rate than face-to-face therapy, is equally effective–and saves the poor therapist from the dress-up routine. The success of therapy through the telephone has something in it to suit just about everyone.

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REFERENCES

Ludman EJ, Simon GE, Tutty S, Von Korff M. A  randomized trial of telephone psychotherapy and pharmacotherapy for depression: Continuation and durability of effects.  Journal of Consulting and Clinical Psychology 2007;  75(2):257-266.

Mohr DC, Hart SL, Howard I, Julian L, Vella L, Catledge C, Feldman MD. Barriers to psychotherapy among depressed and nondepressed primary care patients. Annals of Behavioral Medicine 2006; 32(3):254-8.

Mohr DC, et al. Effect of Telephone-Administered vs Face-to-face Cognitive Behavioral Therapy on Adherence to Therapy and Depression Outcomes Among Primary Care Patients: A Randomized TrialTelephone vs In-Person Therapy for Depression. JAMA 2012; 307(21):2278-2285.

Mohr DC, et al. The Effect of Telephone-Administered Psychotherapy on Symptoms of Depression and Attrition: A Meta-Analysis. Clinical Psychology 2008; 15(3): 243–253.

Simon GE, Ludman EJ, Tutty S, Operskalski B, Von Korff M. Telephone Psychotherapy and Telephone Care Management for Primary Care Patients Starting Antidepressant Treatment: A Randomized Controlled Trial. JAMA. 2004; 292(8):935-942.

VandenBos GR, Williams S. The internet versus the telephone: What is tele-health, anyway? Professional Psychology: Research and Practice 2000; 31:490–492.

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