A brief telephone-based psychotherapy employed soon after starting on
antidepressant medication is associated with significant improvement in
patients' symptoms enduring for as long as 18 months after their first
session, a new study shows.
The report, from the Group Health Cooperative (GHC) Center for Health
Studies in Seattle, appeared in the April Journal of Consulting and
Clinical Psychology. The report, titled "A Randomized Trial of
Telephone Psychotherapy and Pharmacotherapy for Depression: Continuation and
Durability of Effects," follows up on a random sample of GHC patients
who were started on antidepressant therapy after being given a diagnosis of
major depression by their GHC primary care physician. Data on patient outcomes
after six months were reported in a 2004 report in the Journal of the
American Medical Association (JAMA). The research was funded by the
National Institute of Mental Health.
Evette Ludman, Ph.D., a senior research associate with GHC, a health plan
based in Seattle, told Psychiatric News, "With close to 400
patients, our sample represents the largest study to date of psychotherapy
delivered over the telephone. It's also the first to study the effectiveness
of combining phone-based therapy with antidepressant treatment as provided in
everyday medical practice."
Long-term positive effects of 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 received phone-based
therapy reported their depression was "much" or "very
much" improved, compared with 63 percent of those receiving regular
The improvements seen in depression scores on the Hopkins Symptom Check
List (HSCL) between baseline and six months (reported in 2004 in
JAMA) were significantly greater for the patients in the
phone-therapy group compared with the usual-care group. The current report
shows that between months 6 and 18, the added benefit seen with the
phone-therapy group was maintained to the end of the study. Patients in the
phone-therapy group continued to score statistically significantly lower on
the HSCL (about 1.5 at baseline down to an average of 0.68 between 6 and 18
months) compared with those in the usual-care group (about 1.5 at baseline
down to an average of 0.85 between 6 and 18 months).
In addition, the proportion of patients with scores on the Patient Health
Questionnaire-9 (PHQ-9) in the remission range at both the 12- and 18-month
assessments was greater in the phone therapy group (48 percent) compared with
the usual-care group (38 percent)—a difference that just missed
statistical significance (p=0.069).
Those who received phone-based therapy were slightly better at taking their
antidepressant medication as mended, but that did not appear to account for
most of their improvement. 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."
Mirroring real-world clinical practice, the patients' primary care
physicians diagnosed the depression and prescribed antidepressants. Half of
the patients also received eight sessions of telephone psychotherapy during
the first six months, then two to four "booster" sessions and
medication follow-up and support from master's-level therapists in the second
The patients and therapists never met face to face; they only talked over
the phone, said Ludman. Patients weren't always easy to reach by phone, but
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, she said, 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, 75 percent of the 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. However, she noted,
one-fourth of depressed individuals who make appointments for in-person
therapy are no-shows. "They slip through the cracks," she
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 both work and home life. In
addition, Ludman and her colleagues want to compare the effectiveness of
phone-based treatment with that of in-person visits.
The Journal of Consulting and Clinical Psychology can be