Both antidepressant medication and structured psychotherapy have been proven effective, but less than one-third of people with depressive disorders receive effective levels of either treatment, according to background information in the article. Of those beginning psychotherapy, 25 percent attend only one session and only half attend four or more sessions. Stigma remains an important barrier to treatment seeking and treatment adherence. Psychotherapy requires a significant commitment of time.
Gregory E. Simon, M.D., M.P.H., of the Center for Health Studies, Group Health Cooperative, Seattle, and colleagues conducted a randomized trial between November 2000 and May 2002 evaluating two approaches to addressing the barriers to effective depression treatment. The first program was an updated version of a telephone outreach and care management program to improve the quality of antidepressant pharmacotherapy. The second program included telephone care management and added an 8-session structured psychotherapy program delivered by telephone.
The study included 600 patients beginning antidepressant treatment for depression in primary care clinics. The treatments included: usual primary care; usual care plus a telephone care management program including three outreach calls (each contact included a brief, structured assessment of depressive symptoms, antidepressant medication use, and adverse effects), feedback to the treating physician, and care coordination; and usual care plus care management integrated with a structured 8-session cognitive-behavioral psychotherapy program delivered by telephone, with each session lasting 30-40 minutes. Sessions included discussing increasing pleasant and rewarding activities, and identifying, challenging, and distancing from negative thoughts. A participant workbook included in-session exercises and written homework exercises for completion between sessions.
The researchers found that compared with usual care, the telephone psychotherapy intervention led to lower average scores on a scale measuring depression. A higher proportion of patients reported that depression was "much improved" (80 percent vs. 55 percent) and a higher proportion of patients were "very satisfied" with depression treatment (59 percent vs. 29 percent). The telephone care management program without the psychotherapy component had smaller effects on patient-rated improvement (66 percent vs. 55 percent) and satisfaction (47 percent vs. 29 percent); effects on mean depression scores were not statistically significant.
"Telephone programs may sacrifice the richness of traditional in-person therapy, but they address several important barriers to dissemination of effective depression treatments," the authors write. "Vigorous telephone outreach allowed us to engage patients who might not be reached by traditional in-person treatment. Telephone sessions eliminated travel and waiting time and allowed more flexible scheduling. Greater privacy of telephone contacts helped to circumvent stigma."
"Efforts to improve management of depression in primary care must consider resource limitations and pressures to control costs. While we estimate the cost of providing telephone psychotherapy to be less than $50 per session, these additional resources should be directed to those patients most likely to benefit," they add.
"Our findings demonstrate the feasibility, acceptability, and effectiveness of a telephone-based program including medication monitoring, care coordination, and structured, depression-specific psychotherapy. For primary care patients beginning antidepressant treatment, brief structured psychotherapy via telephone adds significantly to usual care pharmacotherapy [drug treatment]. These findings suggest the need for a public health approach to psychotherapy emphasizing persistent outreach and vigorous interventions to improve access to and motivation for treatment," the authors conclude. (JAMA. 2004; 292:935-942. Available post-embargo at JAMA.com)
Editor's Note: This work was supported by a grant from the National Institute of Mental Health. Dr. Simon has received research funding from Eli Lilly & Co. and Solvay Pharmaceuticals. An application for funding is pending with Wyeth Pharmaceuticals. Dr. Simon has also received consulting fees from Pfizer Pharmaceuticals for contributions to a patient education program for people with bipolar disorder. Co-author Dr. Michael Von Korff has received research funding from GlaxoSmithKline Pharmaceuticals and has also received consulting fees from Astra Zeneca Pharmaceuticals for advice regarding pain research.