Brief Phone Therapy Can Boost Antidepressant Benefit

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 care.

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 six months.

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 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 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 accessed at<http://content.apa.org/journals/ccp>.▪