Background: Most primary care patients with depression prefer psychotherapy to antidepressant medication, but access barriers prevent 75 percent of those patients from engaging in and finishing psychotherapy. The most commonly cited barriers include time constraints, lack of available and accessible services, transportation problems, and cost. Psychotherapy conducted by telephone has been proposed to decrease these barriers. Studies show that telephone cognitive behavior therapy (CBT) reduces attrition rates compared with face-to-face CBT, but the effectiveness of the two methods has not been directly compared. Mohr and colleagues designed a randomized controlled trial to compare the effectiveness of each model for the treatment of depression in primary care.
The Study: Participants were recruited from general internal medicine clinics in the Chicago area between November 2007 and December 2010. Patients 18 years or older who met the criteria for major depressive disorder, could speak and read English, and were able to participate in either arm of the study were included. Those with severe psychiatric disorders (including bipolar or psychotic disorders, or significant suicidality), severe substance abuse, dementia, or recent initiation of antidepressant therapy were ineligible. Participants were randomized to telephone or face-to-face CBT and stratified by antidepressant use status. The same PhD-level psychologists provided telephone and face-to-face CBT using the same protocol. All participants were scheduled to receive 18 sessions of 45 minutes each over 18 weeks. Missed appointments were managed the same way in both groups. The primary outcome was adherence to treatment, and secondary outcomes included depression severity and response rate. Follow-up assessments were completed by telephone or online to minimize barriers.
Results: In this intention-to-treat analysis, 325 participants were enrolled to determine a 15 versus 30 percent difference in nonadherence rates. The Patient Health Questionnaire-9 and Hamilton Depression Rating Scale (Ham-D) were used to assess depression severity. Significantly fewer patients stopped telephone CBT before 18 sessions (21 percent) and before five sessions (4 percent) compared with face-to-face CBT (33 percent before 18 sessions and 13 percent before five sessions). Patients in the telephone CBT group attended significantly more sessions than those in the face-to-face CBT group (P = .003). All participants were included in the primary analysis, despite the number of sessions attended. At study end, both modalities treated depression effectively: 27 percent of participants in each group met the Ham-D criteria for complete remission, and similar numbers in each group met the criteria for significant improvement (44 percent in telephone CBT and 49 percent in face-to-face CBT). However, at six months, those in the face-to-face CBT group maintained remission or improvement from baseline, whereas those in the telephone CBT group did not. The authors suggest several possibilities for this difference. A subgroup of patients willing to complete telephone CBT may be more predisposed than others to posttreatment deterioration. Conversely, the act of physically attending therapy sessions or the human contact that occurs during face-to-face CBT may contribute to patients' resiliency after therapy has ended.
Conclusion: For primary care patients with depression, telephone CBT is easier to access and is as effective as face-to-face CBT, but its benefits may not last as long. Long-term follow-up is important to establish the effectiveness of telephone-administered treatment models.