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Phone-based therapy eases depression long term

March 22, 2007

Group Health researchers combine it with drug treatment

SEATTLE— When people receive brief telephone-based psychotherapy soon after starting on antidepressant medication, strong positive effects may continue 18 months after their first session. So concludes a Group Health study in the April Journal of Consulting and Clinical Psychology.

This paper describes one more year of follow-up since a 2004 Journal of the American Medical Association (JAMA) report on the same random sample of Group Health patients.

"With close to 400 patients, this is the largest study yet of psychotherapy delivered over the telephone," said Evette J. Ludman, PhD, senior research associate, Group Health Center for Health Studies, the paper's lead author. "It's also the first to study the effectiveness of combining phone-based therapy with antidepressant drug treatment as provided in everyday medical practice."

Long-term positive effects of initially adding phone-based therapy included improvements in patients' symptoms of depression and satisfaction with their care, said Ludman. At 18 months, 77 percent of those who got phone-based therapy (but only 63 percent of those receiving regular care) reported their depression was "much" or "very much" improved. Those who received phone-based therapy were slightly better at taking their antidepressant medication as recommended, but that did not account for most of their improvement. And effects were stronger for patients with moderate to severe depression than for those with mild depression.

"We were surprised at how well the positive effects were maintained over time," said Ludman. "As with weight control, maintaining improvement is the hardest part of treating depression."

As is usual in clinical practice, the patients' primary care doctors diagnosed their depression and prescribed their antidepressants. Half of the patients also received eight sessions of telephone psychotherapy during the first six months, then two to four "booster" sessions in the second six months as well as medication follow-up and support from masters-level therapists.

The patients and therapists never met face to face, only over the phone, said Ludman. Patients weren't always easy to reach by phone, and the therapists worked hard to reach them all. Therapists followed a structured protocol for psychotherapy. They encouraged the patients to identify and counter their negative thoughts (cognitive behavioral therapy), pursue activities they had enjoyed in the past (behavioral activation), and develop a plan to care for themselves.

"The patients participated more fully in psychotherapy and completed more sessions than do most depressed people in the community," said Ludman. Nationally, only about half of insured patients receiving depression treatment make any psychotherapy visit, and less than a third make four or more visits. By contrast, in this study, three in four patients completed at least six phone therapy sessions. This is striking, she added, because the study did not include people who were already in counseling or planning to be.

"Giving psychotherapy to people with depression who were not seeking therapy may help them significantly," said Ludman. Depression symptoms, including feeling discouraged and avoiding other people, can prevent people from seeking help. One in four depressed people who make appointments for in-person therapy are no-shows. "They slip through the cracks," she added.

Few of the patients who received phone-based therapy—even fewer than those who did not receive it—sought in-person therapy. "This suggests the phone-based therapy met their needs, without whetting their appetite for more," said Ludman. Phone-based therapy is more convenient and acceptable to patients than in-person psychotherapy, she said.

Next, Ludman said, the researchers plan to explore the combination treatment's cost-effectiveness and impact on work and home life. They also want to compare the effectiveness of phone-based treatment with that of in-person visits.

The National Institute of Mental Health funded the study. The other authors are Greg E. Simon, MD, MPH, and Michael Von Korff, ScD, senior investigators at Group Health Center for Health Studies; and Steve Tutty, MA, now a doctoral student in clinical psychology at Brigham Young University in Provo, Utah.

About Group Health Center for Health Studies Founded in 1947, Group Health is a Seattle-based, consumer-governed, nonprofit health care system that coordinates care and coverage. Group Health Center for Health Studies conducts research related to prevention, diagnosis, and treatment of major health problems. It is funded primarily through government and private research grants.

Group Health Cooperative Center for Health Studies