Psychotherapy sessions move to the patient's couch

Teletherapy: A study has found positive results mixing antidepressants with phone calls from therapists.

Medicine & Science

August 30, 2004|By David Kohn | David Kohn,SUN STAFF

In a study sure to please the telecom industry, researchers have found that psychotherapy via telephone can significantly help patients suffering from depression when used in conjunction with antidepressant drugs.

Published in last week's Journal of the American Medical Association, the report is the first large-scale look at the use of the technique.

"Telephone therapy has a lot of potential, based on this study," said Dr. Darrel Regier, director of research at the American Psychiatric Association. "It's a very clever approach."

The experiment involved 600 patients in Washington state, most of whom were moderately depressed.

The patients were divided into three equal groups. One received antidepressant medication only. Another received medicine, along with three brief telephone check-ins over four months from a "care manager."

The third group got medicine, plus eight sessions of telephone psychotherapy over a period of two to four months. The sessions typically lasted 30 minutes to an hour. During the treatments, the therapist and patient never met in person and, in fact, had no idea what the other looked like.

Eighty percent of those in the psychotherapy group reported that their depression was much improved after treatment, compared with 66 percent in the care management group and 55 percent in the medicine-only group.

"With telephone therapy and antidepressants, patients clearly do better," said the study's lead author, psychologist Gregory Simon, a researcher and clinician at Group Health Cooperative, a Seattle-based HMO that covers 500,000 people in the Pacific Northwest.

Regier praised the $1.4 million study, funded by the National Institute of Mental Health, calling it rigorous and "very carefully done."

Psychotherapy has always been regarded as a face-to-face treatment. Many therapists use telephone therapy occasionally, with patients who are on vacation or moving to another area. A handful use it more extensively, but there are no statistics on the technique's prevalence.

The new study could help popularize the approach, particularly for treating depression, which can sap motivation and energy. Unable to rouse themselves from their gloom, depressed patients often miss therapy appointments and stop taking medicines.

Teletherapy can overcome this problem through sheer persistence, the researchers said. If a patient missed a phone appointment during the study, the therapist simply called again later - occasionally more than a dozen times.

About a quarter of the teletherapy patients regularly required multiple calls. But when the therapist finally made contact, the patients were almost always happy to talk, the researchers said.

"When you reached them, they invariably said, `I've been so overwhelmed, but I'm so glad you kept trying to reach me,'" Simon said.

This aggressive outreach goes against psychological convention. Generally, patients with moderate mental illness are left to their own devices, and therapists don't pursue dropouts.

But the standard approach allows too many depressed people to fall by the wayside, Simon said. "If we're going to help people who are depressed," he said. "We'll have to be more active about trying to reach them."

Experts cautioned that telephone therapy lacks the immediacy and richness of the in-person approach.

"If there can be face-to-face therapy, there should be. That's preferable," said Dr. Thomas Nagy, adjunct assistant clinical professor of psychiatry at Stanford University and an expert on the ethics of psychological practice. He cautioned that teletherapists might be more prone to skip key steps, such as taking a detailed patient history.

The Seattle researchers agreed that face-to-face therapy is likely to be more helpful, but they said the telephone allows therapists to reach many patients who would otherwise get little or no treatment.

"[It] may not be as powerful as seeing someone in person," said Evette Ludman, a co-author of the study and psychologist with the Group Health Cooperative. "But it's certainly more effective than not getting any help at all."

For their next study, the scientists are planning to compare telephone therapy with a face-to-face approach.

Because no teletherapy procedures existed, the Seattle scientists had to create their own for the study. "We are pushing this further than it's been pushed before," Simon said.

They based their method on cognitive behavioral therapy, a well-respected approach that emphasizes the use of conscious analysis and decision-making to overcome negative patterns of thinking and behavior. Experts say it relies less on subtle, interpersonal dynamics than many other approaches.

Simon thinks teletherapy could eventually spread widely and said it would be particularly valuable for some groups, including people who are embarrassed or ashamed about visiting a therapist, or rural patients who live far from clinicians.

Ludman said teletherapy could also help make treatment accessible to more poor and minority patients. The study, she noted, included people from a wide range of ethnic groups and income levels.

"These were people who would never show up at a clinic," she said.

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