Depression is undertreated despite the demonstrated efficacy of drugs and psychotherapy. Possible reasons for undertreatment include the stigma attached to depression, patient lack of receptivity to treatment, time needed to experience improvement, and time needed to commit to psychotherapy. Simon and colleagues designed a trial to determine whether a care outreach and telephone contact program could enhance the efficacy of drug treatment, and what added benefits a telephone care management program coupled with telephone-mediated psychotherapy could provide.
Primary care patients who were beginning antidepressant therapy were enrolled in the study and received a baseline assessment to determine depression severity. Consenting participants were randomized to one of three groups: the two intervention programs or usual care. In the telephone care management program, participants were contacted by telephone at two, four, and 12 weeks and by mail at 20 weeks to assess symptoms and medication use. Telephone care managers provided counseling on adverse effects and addressed adherence problems. They also provided crisis intervention as needed. Patients received a self-management workbook they were encouraged to use.
In the psychotherapy program, patients received all the above interventions plus eight sessions of 30 to 40 minutes each of structured cognitive-behavior therapy delivered by telephone, starting two weeks after randomization. Workbook exercises were given to patients to prepare for sessions. Blinded outcome assessments were conducted at six weeks, and three and six months for all participants.
Of 600 patients who agreed to participate, 578 completed at least one assessment, and 532 completed the six-month assessment. The telephone psychotherapy group showed the greatest improvement in depression score, followed by the regular telephone group, and the usual-care group, in that order. These differences increased over the six-month period but were not significantly different between the telephone management group and the usual-care group. Both telephone intervention groups had a significantly higher proportion of participants who were “very satisfied” with treatment, and participants in the telephone pharmacotherapy group were significantly more likely than those in the telephone management group to describe themselves as “much improved” or “very much improved.”
This study confirms the benefits of care management interventions for depression that have been found in other studies. The greatest improvements were found in the telephone psychotherapy program. It is unclear what aspect of the intervention had the greatest effect. The use of antidepressants in appropriate dosages was similar in all groups at the end of the study, although slightly greater in the intervention groups. Telephone contact recipients had a greater number of follow-up contacts than the usual-care patients. Of note, this study suggests that combined psychotherapy and pharmacotherapy work better than pharmacotherapy alone, contrary to the findings of some earlier studies. the authors surmise that this is due to the community-based nature of the trial, a component of which is that telephone contact was easier to achieve in this population than person-to-person therapy. The earlier clinical trials represented a more rarefied setting, where the patients were highly motivated and dealing with highly trained specialists. This study found that telephone psychotherapy was effective and feasible. It works best in patients who have at least moderate depression.