Depression is a common and disabling illness. A variety of treatments, including certain psychotherapies and medications, can help alleviate symptoms. One of the most effective psychotherapies for treating depression is cognitive behavioral therapy (CBT). This therapy helps individuals learn to correct maladaptive thoughts, feelings, and behaviors. In research studies that utilize CBT, therapists are rigorously trained and their sessions are monitored to make certain that they follow specific treatment protocols.
For many reasons, including a shortage of high quality mental health professionals, patients are turning increasingly to their primary care doctors for treatment of depression. Some patients prefer taking medications without psychotherapy; others prefer psychotherapy with or without medications. One of the disadvantages of CBT is that patients may find it difficult to visit a therapist weekly for several months, let alone find qualified therapists who are trained formally in CBT.
A recent study in the Journal of the American Medical Association by David Mohr and colleagues from Northwestern University examined whether telephone-administered CBT works as well as face-to-face CBT, and whether telephone CBT alters compliance with treatment sessions. This study is interesting and important. If patients respond well to telephone-administered psychotherapy, it would allow people who do not live near a therapist to receive this treatment by phone. It also would eliminate the need for travel to and from a therapist's office for those who have the option of face-to-face therapy but have limitations that make it difficult to keep appointments.
Do you think that people participated in phone therapy more, less, or to the same degree as face-to-face therapy? Do you think that therapy is effective if the patient’s only interaction with the therapist is by phone? Is there something therapeutically important about direct face-to-face contact with the therapist? This study offers some interesting and provocative answers.
First, people in this study were more likely to keep their appointments for telephone-administered therapy than for in-person therapy. Approximately 21 percent of people randomly assigned to telephone therapy discontinued treatment compared to about 33 percent of those doing in-person therapy. Interestingly, the increased dropout rate in the face-to-face therapy group occurred early in the treatment course during the first four sessions (of 18 scheduled sessions). The convenience of phone therapy seemed to persuade more participants to stay in treatment.
Second, both phone and in-person therapy led to substantial improvement. By the end of the 18-week study period, both groups of participants improved to the same degree. About 27 percent of patients in each group were considered to be in full remission, meaning that they had few or no residual symptoms. Scores on various clinical rating scales designed to measure depressive symptoms indicated similar clinically significant improvement in both groups.
Face-to-face therapy did show one significant advantage, however. When people were evaluated six months later, both groups remained substantially improved compared to before treatment, but the face-to-face group showed slightly fewer depressive symptoms than the group who received phone therapy.
This study suggests that CBT administered over the phone by trained therapists can be effective. It also suggests that once the treatments are finished, those who received phone therapy should be followed closely by their treatment team since they may have a higher risk for return of symptoms over time. Nonetheless, for those who do not have the time or resources for weekly in-person CBT, phone therapy may provide a viable alternative.
Telepsychiatry offers another way that doctors and other health professionals can reach patients who live in rural areas. This approach involves the use of high resolution video cameras set up in community health centers or other health care settings. Health professionals then can evaluate, observe, and talk with patients in real time. With modern high quality equipment, communication can be very effective.
Another approach that may help patients involves the use of the Internet. Some patients with certain conditions prefer to remain anonymous. Research studying the effectiveness of Internet-based approaches for people with certain types of eating disorders is currently ongoing.
Many of us have grown up thinking that there is no substitute for in-person clinical interactions. Although face-to-face treatments may be a “gold” standard, it is becoming increasingly clear that there are other ways of helping patients suffering from depression and other psychiatric disorders that may be more convenient, affordable, and perhaps as, or nearly as, effective. Thinking out-of-the-box and out-of-the-office may lead to creative and effective ways of helping more people with the limited mental health resources that currently exist.
This column was co-written by Eugene Rubin MD, PhD and Charles Zorumski MD.