Telephone-Based Psychotherapy Shows Durability in Depression

SEATTLE, March 22 -- For depressed patients on medication but too sad to seek psychotherapy as well, lasting help may be available by phone researchers found in a follow-up study.

For more than 75% of nearly 400 patients, the positive effects of six months of brief telephone psychotherapy at the start of antidepressant medication endured for 18 months after the first session, including six months beyond the end of all phone therapy, said Evette Ludman, Ph.D., of the Group Health Cooperative Center for Health Studies here, and colleagues.

This study, reported by Dr. Ludman and colleagues in the April issue of the Journal of Consulting and Clinical Psychology, was a follow-up to a 2004 report on the same sample of 393 patients, published in the Journal of the American Medical Association.

The follow-up found that at 18 months, 77% of those given phone-based therapy reported that depression was "much" or "very much" improved, compared with only 63% of those receiving usual care.

In the 18-month analysis, the benefits of telephone psychotherapy in the first six months were sustained during the second six months when only brief booster sessions were provided. Significantly a "robust clinical benefit" endured for six months after all treatment contact was discontinued, the researchers found.

"As with weight control," Dr. Ludman said, "maintaining improvement is the hardest part of treating depression."

Traditional in-person psychotherapy has limited reach among the large number of patients beginning antidepressant treatment in primary care, the researchers wrote. Expanding access to therapy calls for considering new therapy approaches, such as phone-based sessions, that place greater emphasis on accessibility, outreach, and patient convenience, the investigators concluded.

Of the participants, 195 were randomly assigned to antidepressant medication and usual care while 198 got medication and phone therapy. Of these, 348 (89%) completed the six-month blinded assessment, and 334 (85%) completed the 18-month follow-up.

On average, all patients reported a moderate level of depressive symptoms at baseline, two to four weeks after starting antidepressants prescribed by a primary-care provider.

Phone psychotherapy sessions, delivered by masters-level therapists, included eight core sessions (about 30 minutes) during the first six months, with 15- to 20-minute booster sessions every two months up to a year. After that, phone therapy ended.

According to a structured cognitive behavioral-based psychotherapy program, patients were encouraged to identify and counter their negative thoughts (cognitive behavioral therapy), pursue activities they had enjoyed in the past, and develop a plan to care for themselves.

Other study findings were:

• Telephone participants were more likely to receive adequate antidepressant medication in any of the three periods, although the difference was quite modest and not statistically significant. This finding suggests that drug therapy was not a major mediator of the positive effect in this study, the researchers said.
• Patients participated more fully in psychotherapy in the telephone program than is usually seen in community-based practice, in which fewer than 30% of depressed adults continue treatment.
• Although participants in both groups were free to seek in-person psychotherapy, less than 25% did, and only 20% of these remained in treatment for six or more visits. This suggests that phone-based therapy met the patients' needs, the researchers said.

Because depression is characterized by low motivation, lack of energy, and impaired problem-solving abilities, keeping patients in depression treatment programs may require a different strategy, the researchers said.

Telephone-delivered psychotherapy, characterized by convenience and outreach, may reach these patients, as well as those who are homebound or disabled, or those living in rural or underserved areas, the researchers said.

Several limitations should be considered, they said, including the fact that these findings may not be generalizable to other settings or populations, especially since a third of potential participants declined to complete the initial assessment.

Also, the researchers could not determine the specific elements of phone therapy that were effective, nor could they separate specific contents of the program from nonspecific elements of purely supportive contact.

Unfortunately, they said, the type of therapy in this program is not yet reimbursable under current insurance plans, although this technique has many features in common with telephone-delivered case-management services that are increasingly common.

Finally, they suggested, further research should be directed toward dismantling the telephone program to determine its effective components and as a stand-alone treatment for those with less severe depression.