Improving the effectiveness of depression treatment in primary care may be
as simple as picking up the telephone to provide vital interaction and
follow-up with patients initiating antidepressant therapy.
Integrating a structured cognitive-behavioral therapy (CBT), delivered over
the phone, into a pharmacotherapy-based depression treatment plan may
significantly improve not only patients' depression-scale scores and increase
rates of response and remission, but may also improve patients' satisfaction
with depression treatment, according to new research.
Gregory Simon, M.D., M.P.H., a psychiatrist at the Center for Health
Studies at Group Health Cooperative (GHC) in Seattle, and colleagues conducted
a randomized, controlled trial comparing usual primary care treatment for
depression to usual care plus a telephone care-management program, and to the
care-management program supplemented by phone-based CBT. Results of the study,
funded by the National Institute of Mental Health, were reported in the August
25 Journal of the American Medical Association.
Simon's group followed 600 patients who were from seven primary care group
practices and had received a prescription for antidepressant medication from a
GHC doctor. GHC is a group health plan covering just over 500,00 patients in
Each patient underwent a baseline assessment including the Hopkins Symptom
Checklist Depression Scale (SCL) and the Patient Health Questionnaire (PHQ).
Patients were then randomly assigned to one of three groups. The first group
was followed under "usual care" and was not contacted again until
the first planned outcome assessment. Patients assigned to the telephone
care-management (TCM) intervention group were contacted by care
managers—mental health professionals with a bachelor's or master's
degree and at least one year of experience in depression
assessment—within four weeks after receiving their antidepressant
Care managers made two additional phone contacts for each patient in the
TCM group, occurring four and 12 weeks after the first phone call, and also
mailed a personalized contact about 20 weeks later. Each contact included a
brief structured assessment of depressive symptoms, antidepressant use, and
adverse effects. Treating physicians received systematic reports including
summary assessment information and computer-generated recommendations
regarding medication adjustment. If a change in medication was made, the care
manager worked to facilitate patient-physician communications. The care
managers were also available for as-needed crisis intervention and referrals
to mental health specialty care if warranted.
Each patient in TCM also received a detailed self-management workbook that
emphasized behavioral activation, identifying and challenging negative
thoughts, and developing long-term self-care plans. Care managers gave
recommendations on workbook activities but no specific counseling.
For those patients assigned to the group receiving telephone
care-management plus psychotherapy (TCM/CBT), in addition to following the
same protocol as the TCM patients, TCM/CBT patients received a structured
eight-session CBT program with 30- to 40-minute sessions over the phone every
two to four weeks throughout the study. For this group, telephone counselors
had master's degrees and at least one year of experience in outpatient
psychotherapy of depression.
All participants were contacted for a blind telephone outcome assessment at
six weeks, three months, and six months after randomization. Each patient
completed a self-rated measure of global improvement and was administered the
SCL. At the three- and six-month assessments, patients were also administered
the PHQ and a rating of satisfaction with depression treatment.
At baseline, patients reported a moderate level of depressive symptoms,
roughly two to four weeks after starting antidepressant therapy. Improvement
in SCL depression scores was greatest in the TCM/CBT group, intermediate in
the TCM group, and least in the usual-care group.
The TCM/CBT group showed statistically significant improvements in
depression scores. The effectiveness of both interventions varied according to
baseline severity, with no apparent effect in those with mild baseline SCL
scores, and similar effectiveness between those with moderate to severe
symptoms at baseline.
In addition, Simon's group found, patients assigned to TCM were
significantly more likely to use antidepressants at an adequate dose for at
least 90 days. The trend was the same for the TCM/CBT group; however, the
result did not reach statistical significance.
"Telephone programs may sacrifice the richness of traditional
in-person therapy," Simon and his coauthors wrote, but they"
allowed us to engage patients who might not be reached by traditional
The success, the researchers proposed, may be tied to the fact that"
level of therapist activity differed significantly from the traditional
office-based therapist's role," in the significant number of outreach
calls and mailings to patients who did not respond to phone calls.
"Such a public health approach—rather than a traditional
clinical approach—may be necessary to actually provide empirically
supported psychotherapy to the majority of depressed patients not now
The catch is, Simon told Psychiatric News, "this type of
treatment is not currently reimbursable. And as long as people are not going
to be paid for it, they are not necessarily going to implement it. But the
program certainly would be appropriate in large group health plans.
"It's not, of course," he added, "the kind of thing most
primary care doctors are going to implement in their own practices."
An abstract of "Telephone Psychotherapy and Telephone Care
Management for Primary Care Patients Starting Antidepressant Treatment,"
is posted online at<http://jama.ama-assn.org/cgi/content/short/292/8/935>.▪